evaluation of the design & dignity - hospicefoundation.ie · and calm cannot be underestimated....

Evaluation of the

Design & Dignity PROGRAMME

Beaumont Mortuary Glasswork Michelle O’Donnell, Glasshammer Studio

Evaluation of the Design & Dignity Programme

i

The following evaluation was conducted by University College Cork (UCC), led by the

School of Nursing and Midwifery and commissioned through the All Ireland Institute

of Hospice and Palliative Care (AIIHPC) in collaboration with the Irish Hospice

Foundation. The Design & Dignity programme is a partnership programme of the

Irish Hospice Foundation and the Health Service Executive (HSE).

Acknowledgements

The evaluation team would like to thank all the sites for their participation,

facilitating site visits, responding to emails, and taking part in focus groups.

Gratitude is extended to the research staff who worked on this project,

namely Ms. Olivia Cagney and Dr Elaine Meehan.

Furthermore, the team would like to thank all the patients, staff and bereaved

relatives for contributing to this evaluation and making it a representative and

comprehensive report on a very important and impactful programme.


ii

The Evaluation Team

Dr Nicola Cornally (PI) 1

Dr Serena FitzGerald (Co-PI)1

Ms Olivia Cagney (Research Assistant)

Dr Aileen Burton1

Dr Alice Coffey 2

Ms Caroline Dalton1

Dr Irene Hartigan1

Dr Jim Harrison3

Dr Margaret Murphy1

Dr Daniel Nuzum4

Ms Yvonne Pennisi5

Professor Eileen Savage1

Dr Catherine Sweeney6

Dr Suzanne Timmons7

Dr Patricia Leahy Warren1

Recommended Citation

Cornally, N., Cagney, O., Burton, A., Coffey, A., Dalton, C., Hartigan,

I., Harrison, J., Murphy, M. Nuzum, D., Pennisi, Y., Savage,

E., Sweeney, C., Timmons, S., Leahy Warren, P., & FitzGerald,

S. (2019). Evaluation of the Irish Hospice Foundation Design

& Dignity Programme. University College Cork, Cork.

Contact person for communication:

Dr Nicola Cornally (PI)

Email: [email protected]

Tel: +353-21-4901478

1 Catherine McAuley School of Nursing and Midwifery, University College Cork

2 School of Nursing and Midwifery, University Limerick

3 Cork Centre for Architectural Education

4 Pastoral Care, Marymount University Hospital and Hospice Department of Obstetrics and Gynaecology, University

College Cork.

5 Occupational Science and Occupational Therapies, University College Cork

6 School of Medicine University College Cork & Marymount University Hospital and Hospice

7 Centre for Gerontology and Rehabilitation, University College Cork


iii

Foreword

On behalf of the Irish Hospice Foundation (IHF), I am honoured to provide the foreword to this report,

which also marks the announcement of our fourth round of Design & Dignity Projects.

Design & Dignity was launched in 2010 and at the time of this publication over 40 projects have been

funded across Ireland.

The vision of Design & Dignity is that every adult, pediatric and maternity hospital in Ireland has warm

and welcoming spaces to enable dignity and respect for patients and families facing dying, death and

bereavement.

It is clear from the impact of the various projects described in this report alongside the evaluation by the

UCC Research Team that Design & Dignity has succeeded in one of its major aims to create end-of-life

sanctuaries for patients, families and staff at an extremely difficult time. In human terms, the impact of

hearing bad news or saying farewell to a loved one in a space that is sensitively designed, appropriate

and calm cannot be underestimated.

I am particularly struck by how this flagship project is significantly shaping the overall culture of end-of-

life care in Irish hospitals. It is truly wonderful to see the level of pride that staff feel having played a

vital role in bringing their Design & Dignity projects to fruition. I know their vision, dedication and tenacity

to improving the standard of end-of-life care will be a source of inspiration and stimulation for others

considering the Programme.

The success of Design & Dignity is due to a strong and long-lasting partnership between the IHF and

HSE Estates. The IHF, through its dedicated administrative function and design expertise, has enabled

this work to be prioritised but without the HSE Estates’ leadership and commitment these projects could

not have been completed.

Much has been achieved through Design & Dignity but improvements are still needed. Together with

HSE Estates, hospital staff and our Design & Dignity Committee, we will continue to pave the way for

rooms and other spaces which are places of beauty and comfort for people and their families in Irish

Hospitals. We commit to continue our work to create oases of calm, privacy and peace for families and

staff throughout Ireland.

Jean McKiernan; Chairperson of the Board of the Irish Hospice Foundation


iv

Foreword

On behalf of HSE HBS Estates, I welcome this evaluation report by University College Cork (UCC)

on the Design & Dignity initiative, which HBS Estates delivers in partnership with the Irish Hospice

Foundation.

HBS Estates, the Estates unit within the HSE, is responsible for the development and management of

the healthcare estate to enhance wellness in our patients and clients and to enable and encourage

our healthcare staff. HBS Estates is also responsible for ensuring that the healthcare infrastructure

supports the efficient delivery of services and delivers value for money.

In the past, all too often the focus of capital development and investment in healthcare has been on the

provision of bed numbers and the expansion and improvement of clinical areas. The introduction and roll

out of the Design & Dignity initiative and concept is challenging us to ensure that end-of-life care takes

centre stage in the projects delivered by the initiative. As part of this, we aim to provide much needed

private, respectful, dignified and comfortable spaces for patients and families within the wider hospital

environment, during difficult times. HBS Estates is proud to have adopted the Design & Dignity style

guidelines in all new building and refurbishments projects relating to end-of-life care in hospitals that we

work in.

This evaluation report highlights the success of the Design & Dignity initiative in delivering a significant

number of projects that deliver on the key aims and objectives of the initiative; to transform the way

hospital spaces are designed for people at the end-of-life and their families, to foster ownership of these

spaces by involving staff in their design and ultimately to create exemplar end-of-life facilities for patients

and families.

The Design & Dignity initiative continues to develop and be driven by the experiences of the projects to

date and from the expertise and input of both project stakeholders and the Design & Dignity committee.

A lot can, and will, be taken and learnt from this evaluation report to further improve and strengthen the

delivery of future projects part of the Design & Dignity initiative.

I would like to take this opportunity to thank all of those staff, stakeholders and designers who have

invested time and resources, ideas and passion into the projects to date. We are committed to

continuing to work with our wide range of internal and external stakeholders to support and deliver the

objectives of Design & Dignity in partnership with the Irish Hospice Foundation.

John Browner, Assistant National Director, Capital Property, HSE HBS Estates


v

Executive Summary

The Design & Dignity Programme, in partnership with the Irish Hospice Foundation (IHF) and Health

Service Executive (HSE), was launched in 2010 to create a model or ‘exemplar’ projects within acute

hospital facilities.

Through the use of the Design & Dignity guidelines this programme has provided support and funding

for over 40 projects throughout Ireland. Hospital spaces have been redesigned in areas such as family

rooms, mortuaries, viewing rooms and bereavement suites. This programme has ensured that hospitals

offer quiet and peaceful places for family members and friends to avail of when someone close to them

is dying. Empirical research has repeatedly highlighted the impact of evidence-based design in end-of-life

acute care settings. Key factors associated with improved outcomes include the use of efficient space

allocation, providing user friendly spaces and ensuring privacy for patients and their families. Homely

environments, where personalisation and social interaction can occur is of key importance as well as

having contact with nature, low noise levels and the option to avail of either single or mixed occupancy

rooms.

The aim was to independently evaluate the Design & Dignity programme with a focus on establishing

impact of Design & Dignity projects on patients, their families and acute hospital staff. The evaluation

utilised a post occupancy framework which incorporated indicative and investigative data collection

methods. To achieve this 18 site visits were conducted and data was collected on; physical dimensions

(meters), light (lux) and noise (decibels), IHF audit tools and qualitative field notes. This report presents

an evaluation of the impact of the first two rounds of Design & Dignity funded projects. These projects

involved the development of nine family rooms, five mortuaries, an emergency department bereavement

suite and three rooms to support families in maternity services. An in-depth evaluation was also

undertaken in five key hospital sites; Roscommon Hospital, Mater Misericordiae University Hospital

Dublin, Beaumont Hospital Dublin, St. James’s Hospital Dublin and St. Luke’s Hospital Kilkenny. These

case studies were informed by focus groups with staff (n=18), patient/relative interviews (n=4) and real-

time comment cards. This was in addition to site visits and analysis of facility documents.

The provision of these facilities was seen to positively impact on the end-of-life culture in acute

hospitals, families, staff and patients. Firstly, providing these forms of facilities sent out a clear

message that end-of-life care in acute care hospitals matters; these facilities impacted on the culture

of care ensuring that the death of an individual and supporting the families involved was viewed as an

important aspect of acute care within hospital facilities. Being able to provide appropriate end of life

supports to families instilled great pride in staff who previously had been embarrassed at having to

support families on corridors or other public places. The facilities developed as a result of the Design &

Dignity Grant Scheme, provided staff with a dignified and private environment in which they could engage

in caring, compassionate interactions with family members. These spaces provided an oasis of calm

for families at difficult times in their lives. Families and patients had access to a secluded and serene

environment, while crucially, remaining in close proximity to their loved ones, within the hospital setting.

On a practical level, it gave families somewhere to go while the care needs of their loved one were being

met and helped reduce the financial burden often experienced by these families by providing a facility

where they could have freely available refreshments.


vi

Project level challenges were identified by staff across all the sites, with common issues such as

securing corporate commitment, negotiating timelines with contractors, educating staff on the function

and use of the space. Many spoke about the facilitators to overcoming these issues and frequently

referred to the support from the IHF, particularly in terms of the style guidelines and the architect.

Having a dedicated committee with a genuine focus on improving end-of-life care in acute care was the

facilitator for real progression and ensured on-going governance and sustainability. Once all levels of

staff could see and experience the impact the new space had, a rippling effect took place throughout the

organisation.

This report makes a number of recommendations for future builds including that the Design & Dignity

facilities should be the norm, not a luxury. Such facilities should be included in the planning of all new

builds, closely involving architects with an interest in this field from the outset. High quality furnishings

and artwork should be available in these rooms and all rooms should be fully serviced and future-

proofed to keep abreast with new technologies. Both the establishment of multidisciplinary end-of-life

care committees, as well as the development and implementation of staff education programmes on the

use of these facilities is a key requirement in acute hospital settings.

In conclusion the Design & Dignity projects were described as symbolic of compassion and

demonstrated that the organisation valued the experience of those grieving. Design & Dignity grants not

only transformed physical spaces but, according to staff, transformed end-of-life care and have been the

catalyst for dignified care in acute care settings. The new spaces have ensured that these principles are

no longer aspirational but rather rooted in the culture of end-of-life care.

‘the space is very important but it’s the philosophy of valuing the experience and acknowledging the importance of this death that is happening… this is really important” (Clinical Staff)


vii

Table of Contents

Chapter 1: Background ...............................................................................................................01

1.1 Introduction ................................................................................................................02

1.2 The Design & Dignity Programme .................................................................................03

1.2.1 Funded projects directory ...............................................................................04

1.3 Evidence-Based Healthcare Design ...............................................................................05

Chapter 2: External Evaluation ....................................................................................................07

2.1 Introduction ................................................................................................................08

2.2 Methodology ...............................................................................................................09

2.2.1 Post occupancy evaluation .............................................................................09

2.2.2 Indicative level ..............................................................................................09

2.2.3 Investigative level ..........................................................................................10

2.2.4 Healthcare and Support Staff .........................................................................10

2.2.5 Participants and Procedure .............................................................................10

2.2.6 Bereaved Relatives ........................................................................................10

2.2.7 Comment Boxes ............................................................................................11

2.3 Overview of Design & Dignity Projects ...........................................................................11

2.3.1 Beaumont Hospital, Dublin – Family Room .......................................................14

2.3.2 Connolly Hospital, Dublin – Family Room .........................................................15

2.3.3 Galway University Hospital – An Seomra Ciuin Maternity Ward ...........................16

2.3.4 Mercy University Hospital, Cork – Mortuary ......................................................17

2.3.5 Mayo University Hospital – Family Room ..........................................................18

2.3.6 Mid-Western Regional Hospital, Nenagh – Family Room ....................................19

2.3.7 Mid-Western Regional Hospital, Limerick – Mortuary .........................................20

2.3.8 Our Lady’s Hospital, Navan – Family Room .......................................................21

2.3.9 Portiuncula Hospital, Galway – Family Room .....................................................22

2.3.10 Sligo Hospital – Mortuary ...............................................................................23

2.3.11 St John’s Hospital Limerick – Family Room ......................................................24

2.3.12 University Maternity Hospital, Limerick – Maternity Room ..................................25

2.4 Indicative Level Summary Analysis ..............................................................................26

2.4.1 Mortuary measurements and audit tool results ................................................26

2.4.2 Family room ..................................................................................................28

2.4.3 Bereavement suite (viewing suites and maternity units) ...................................30

2.5 Five Case Studies .......................................................................................................32

2.5.1 St. Luke’s Maternity Hospital – Maternity Room ...............................................32

2.5.2 Mater Misericordiae University Hospital – Family Room .....................................34

2.5.3 Beaumont Hospital – Mortuary .......................................................................36

2.5.4 St. James’s Hospital Emergency Department – Bereavement Suite ....................38

2.5.5 Roscommon Hospital – Mortuary ....................................................................40


viii

2.6 Overarching Themes ....................................................................................................42

2.6.1 Investigative Level – Staff Focus Groups ..........................................................42

2.6.2 Investigative Level – Family and Patient Feedback ............................................48

Chapter 3: Recommendations & Reflections ................................................................................53

3.1 Key Challenges and Lessons Learned ...........................................................................54

3.1.1 Project Level Challenges ................................................................................54

3.1.2 Project Level Facilitators .................................................................................55

3.2 Recommendations ......................................................................................................55

3.2.1 Project Type Level: Mortuary, Family Rooms and Bereavement Suites .................56

3.2.2 Organisational Level ......................................................................................59

Bibliography ...............................................................................................................................63

Appendices ................................................................................................................................65

Appendix 1 Summary of Empirical & Grey Literature ..........................................................65

Literature Review at a glance ..........................................................................67

Overview of grey literature recommendations ...................................................75

Appendix 2a Emergency Department Bereavement Suite Assessment Tool ...........................76

Appendix 2b Mortuary Assessment Tool .............................................................................78

Appendix 2c Family Room Assessment Tool ........................................................................80

Appendix 3 Topic guides ..................................................................................................81

Appendix 4 Light and Sound Recommendations for Hospital Settings .................................84

Appendix 5 Qualitative Themes, Subthemes and Codes .....................................................85

Appendix 6 Comment box responses................................................................................86

List of Tables

Table 1. Funded projects directory ................................................................................................04

Table 2. Total number of participants per sites ...............................................................................10

Table 3. Indicative measurements/audit tool scores per mortuary site ............................................27

Table 4. Indicative measurements/audit tool scores per family room site.........................................29

Table 5. Indicative measurements/audit tool scores per bereavement suite site .............................31

List of Figures

Figure 1. List of hospitals included in evaluation ............................................................................08

Figure 2. Facility documentation and POE per site and relationship to study objective .......................09

Figure 3. Overview of project types................................................................................................11

Figure 4.

Figure 5. Field note synthesis of key terms used for mortuary sites.................................................28

Figure 6. Field note synthesis of key terms used for family room sites .............................................30

Figure 7. Field note synthesis of key terms used for bereavement suite sites ...................................31

Figure 8. Impact on Staff .............................................................................................................46

Figure 9. Family and patient perspectives ......................................................................................52

Figure 10. Project challenges ......................................................................................................54


1

Chapter 1: Background


2

1.1 Introduction

In Ireland, on average, only 26% of 28,000 deaths each year take place in the home, while 43% occur

in the hospital setting (Murrary et al., 2013).

The environment in which people die can have a huge impact on the individual’s experience as well as

their relatives’ memories of the death.

The Design & Dignity Grants Scheme was officially launched in 2010 to highlight the importance of the

often-overlooked physical environment in providing dignified end-of-life care to patients, their families and

friends. The scheme endeavoured to create model or “exemplar” projects within hospital facilities to

guide the development of future facilities related to end-of-life care. It also sought to enhance the culture

surrounding end of life issues.

This report describes the work of eighteen hospital projects throughout the Republic of Ireland, which

were created as part of the Design & Dignity Programme. The eighteen projects were developed to

enhance the physical environment to support end-of-life care. This report was designed to evaluate the

Design & Dignity Programme, with a focus on establishing impact of projects on patients, their families

and acute hospital staff. The report is divided into three chapters:

Chapter one will introduce the Design & Dignity Programme and provide a background to its

scope and purpose including an overview of evidence-based design in end-of-life care in acute

care settings.

Chapter two will present each of the facilities involved in the evaluation. The facilities will be

presented with photographs to capture its detail and design features and includes indicative

level analysis. This chapter also will give in-depth evaluation of the experiences of staff and

relatives who have used the Design & Dignity spaces.

Chapter three will discuss the key challenges and lessons learnt together with recommendations

for future and existing Design & Dignity spaces.


3

1.2 The Design & Dignity Programme

The Design & Dignity Programme established by the Irish Hospice Foundation (IHF) and Health

Service Executive (HSE) aims to ensure that hospitals offer quiet and peaceful spaces for family

members and friends to help them cope when someone close to them is dying.

It highlights the importance of the often-overlooked physical environment in providing dignified end-of-life

care to patients, their families and friends.

A review carried out in 2007 by Tribal Consulting on behalf of the IHF found hospital facilities were

lacking in terms of care, death and bereavement care across Ireland (Irish Hospice Foundation, 2007).

Specifically, the review highlighted concern in the following areas:

an absence of facilities to have private and sensitive conversations

a lack of dedicated family areas

shortage of single patient room accommodation for those at end of life

rundown mortuary facilities and family rooms

little attention to detail or natural surroundings

inflexible facilities for different religions and cultures

In October 2010 the Design & Dignity Grants Scheme was officially launched. Since its inception, the

Design & Dignity programme has provided support to over 40 projects throughout Ireland. Such projects

have created relaxing, spacious family rooms within busy acute wards, upgraded mortuaries into

welcoming, respectful environments and redesigned dreary facilities into spaces of tranquillity. Areas in

which projects have been completed include acute wards, mortuaries, emergency departments, waiting

areas and maternity units.


4

Hospital Project Type Artwork type and Artist details

1 Beaumont Hospital, Dublin Family Room Artwork Yvonne Coomber, Gaslamp Gallery

www.thegaslampgallery.com

2 Beaumont Hospital, Dublin Mortuary Glass Art Michelle O’Donnell, Glasshammer

studio, [email protected]

3 Connolly Hospital

Blanchardstown, Dublin

Family Room Eunan Sweeney Photography

087 648 8660

4 Mater Misericordiae

University Hospital

Family Room Artwork Rebeka Khan

www.rebekakahnartwear.com

5 Mayo University Hospital Family Room Artwork Francois Gunning

www.francoisgunning.com

6 Mercy University Hospital

Cork

Mortuary Existing stained glass windows, interiors by Reddy

Architects, wallpaper stock images

7 Mid-Western Regional

Hospital, Limerick

Mortuary Monika Mulhall

[email protected]

8 Nenagh General Hospital,

Tipperary

Family Room Gareth MCCormack

www.garethmccormack.com

9 Our Lady’s Hospital,

Navan

Family Room Ceramic Artwork Diane McCormick

www.dianemccormick.co.uk

10 Portiuncula Hospital

Ballinasloe, Galway

Family Room Patrick McKeown Photograher

mckeonphotography.com

11 Roscommon University

Hospital

Family Room Shutterfever Photography

[email protected]

12 Roscommon University

Hospital

Mortuary Orla Kennelly

[email protected]

13 Sligo General Hospital Mortuary Vera Gaffney Prints, Quilt by local Yeats Country

Quilters, Breda McNeill, Glass butterflies by Anna’s

Gift gallery. Framed poem by WB Yeats

14 St. James’s Hospital,

Dublin

Bereavement

Suite

Artwork and Feature Panels Michelle O’Donnell,

Glasshammer studio, www.glasshammer.ie

15 St. Johns Limerick, Family Room Artwork Kilkenny Design Shop, Dublin

16 St. Luke’s General Hospital

Kilkenny

Maternity

Family Room

Stained Glass Paschal Fitzmaurice

087 202 1633

17 University Hospital Galway, Maternity

Inpatients Room

Marielle Macleman

[email protected]

18 University Maternity Hospital

Limerick

Maternity

OPD Meeting

Room

Artist not known

1.2.1 Funded projects directory


5

1.3 Evidence-Based Healthcare Design

From 2007 to 2012, a total of 32 acute public hospitals, and 18 community hospitals were actively

involved with the Hospice Friendly Hospitals (HfH) programme (Clarke and Graham, 2013).

As a result of this programme a working group including senior nurses, palliative care specialists,

healthcare quality experts, HfH programme staff and consultant architects developed a set of guidelines

for Physical Environments of Hospitals Supporting End-of-life care. Central to the programme is The

Design & Dignity Scheme (Clarke and Graham, 2013, Walsh, 2013), a partnership programme between

the Irish Hospice Foundation and Health Service Executive Estates. The HfH programme seeks to create

positive change in the manner in which people die in acute hospitals. In Ireland, only 26% of 28,000

deaths each year take place in the home, while 43% occur in the hospital setting (Murrary et al., 2013)

The Design & Dignity scheme aims to bring design excellence to hospitals at a critical time at the end

of life for the person who is dying, their family and for hospital staff. Support has been provided to 40

projects throughout Ireland e.g. hospitals have created relaxing, spacious family rooms within busy

acute wards, upgraded mortuaries into welcoming, respectful environments and redesigned viewing

rooms in emergency departments and mortuaries. Feedback from families and staff has been positive

demonstrating that, with relatively small investments a difference can be made (Walsh, 2013).

Design & Dignity guidelines aim to create a warm and welcoming environment for those being cared

for at the end of their lives in a hospital setting (Irish Hospice Foundation, 2014). Current evidence

indicates that the physical characteristics of a hospital environment influences patient’s quality of care

(McKeown et al., 2010). Practice guidance on design, dignity and privacy in care has highlighted key

recommendations in several areas to improve care and attention to detail of hospital environments (Irish

Hospice Foundation, 2007). Among these include sizing and reconfiguration of single rooms, accessible

facilities, natural light, visitor considerations and multi-denominational use of space (Irish Hospice

Foundation, 2007).


6

The establishment of a dedicated hospital space can provide both privacy and family proximity at end

of life for individuals who are unable to die at home (Slatyer et al., 2015). Control, comfort, sensitive

communication, peace and family inclusion have been identified as influential factors that improve the

quality of death and dying (Stajduhar et al., 2011, Willard and Luker, 2006). In addition, a sense of

homeliness and aesthetic influences can encourage positive emotions (Timmermann et al., 2015)

Despite policy initiatives to enhance end-of-life care in the community, many individuals also require

end-of-life care in hospital settings (Brereton et al., 2012). Empirical research continues to reflect on a

consistent interrelationship between the patient, hospital environment and improved health outcomes

(Timmermann et al., 2015). Yet, there is limited evidence with regard to the optimum physical hospital

environment for patients and their families at end of life (Gardiner et al., 2011). Research has focused

on patient, family members, and healthcare professional’s experiences and perceptions of physical

hospital environments. Despite concerns regarding the layout and design of hospital environments,

there is little evidence to determine the impact of newly designed hospital spaces for individuals, their

families, and staff at end of life, hence the importance of this evaluation. A review of the empirical and

grey literature was conducted to inform the impact and outcomes of evidence-based design on end-of-life

care in acute settings. Findings from the review informed data collection methods and provided context

for future recommendations. For an overview of the empirical and grey literature see Appendix 1.


7

Chapter 2: External Evaluation


8

MayoSligo

Donegal

Tyrone

Fermanagh Armagh Down

AntrimDerry

Monaghan

CavanLeitrim

Galway

RoscommonLongford

Clare

Tipperary

Limerick

Cork

Waterford

WexfordKilkenny

Carlow

Wicklow

Kildare

Laois

Offaly

Westmeath Meath

Louth

Dublin

Kerry

13

1017

5

16

6

8

9

1 2

4 14

3

11 12

7 15 18

2.1 Introduction

This section describes the methodology used to evaluate the Design & Dignity Programme.

As specified by the Irish Hospice Foundation, the aim was to independently evaluate the Design &

Dignity programme with a focus on establishing impact of projects on patients, their families and acute

hospital staff. In order to meet this aim, two objectives were proposed. The first, and primary objective

was to assess the impact of evidence-based design from the perspectives of patients, families and

staff (including frontline staff and HSE Estates), specifically focusing on: a) the impact on the culture

of care, b) the impact on the organisation of care, c) the design features of the new facilities which

have the most impact and d) knock-on and unforeseen benefits/challenges emerging from the projects.

The secondary objective was to determine likely factors contributing to the successful completion

and maintenance of Design & Dignity spaces. A total of 18 facilities were included in the evaluation

illustrated in Figure 1. The type of facilities ranged from family rooms, maternity rooms, mortuaries and

emergency department bereavement suites.

1. Beaumont Hospital, Dublin

2. Beaumont Hospital, Dublin

3. Connolly Hospital, Dublin

4. Mater Misericordiae University

Hospital

5. Mayo University Hospital

6. Mercy University Hospital, Cork

7. Mid-Western Regional Hospital,

Limerick

8. Nenagh General Hospital,

Tipperary

9. Our Lady’s Hospital, Navan

10. Portiuncula Hospital Ballinasloe,

Galway

11. Roscommon University Hospital

12. Roscommon University Hospital

13. Sligo General Hospital

14. St. James’s Hospital, Dublin

15. St. John’s Hospital, Limerick

16. St. Luke’s General Hospital,

Kilkenny

17. University Hospital, Galway

18. University Maternity Hospital,

Limerick

Figure 1. List of hospitals included in evaluation


9

2.2.2 Indicative level

Indicative level evaluation involved a “walk-through” of all eighteen Design & Dignity spaces (while

unoccupied) using a GoPro camera to capture detail on setting appearance and contents. In order to

compare with universal standards, measures were taken of the spaces physical dimensions (meters), its

light content (lux) and noise content (decibels). Additionally, IHF audit tools (on setting appearance and

contents – see appendix 2 a-c). Qualitative field notes were taken by the researchers to describe what

they saw, smelt, heard and felt during site visits.

Design Focus Multi-Case Study/Approach Study Objectives

Facilit

y

Docum

enta

tion

Generic Documentary Analysis of Project Overview File including

photographs and site maps

Informs study

objectives 1 (a-c)

Outcomes:

– Overview of design attributes

– Provides data on outcome measures and photographic

evidence to inform observation assessments, focus groups and

semi-structured interviews at indicative and investigative level

– Overall informs standarised framework of in-depth case studies

Post

Occupancy

Docum

enta

tion

Level 1

Indicative

Walk through, observation checklist Meets study

objectives 1 (a-d)

& 2 (limited)Outcomes:

– Overview of the positive and negative aspects of the buildings

performance and usage within the use of limited resources

Level 2

Investigative

Behavioral observation, focus groups, semi structured interviews,

benchmarking with literature and state of the art facilities

Meets study

objectives

1 (a-d) & 2

(comprehensive)Outcomes:

– Results is in-depth evaluation of the facility

Figure 2. Facility Documentation and POE per site and relationship to study objective

2.2 Methodology

2.2.1 Post occupancy evaluation

The design of this evaluation involved multiple case study research informed by best practice in Post

Occupancy Evaluation (POE). The core aim of POE is to gain feedback on the success of the build from

the perspective of the end-users following a period of intended use (Fronczek-Munter, 2013). Battisto and

Franqui (2013) propose a best practice framework for evaluating evidence-based healthcare design which

encompasses a two-phased facility-based case study approach; facility documentation followed by a POE

(Battisto and Franqui, 2013). Facility documentation ensures that the design attributes of a build are

captured and that information regarding the anticipated outcomes of the project can be determined and

subsequently measured as part of the POE. As part of the POE framework a multi-case study approach

was applied. Illustrated in Figure 2, the POE has a two levelled approach. Level 1 described as Indicative

is a basic evaluation of the facility whereas Level 2, Investigative is a more in-depth evaluation.


10

2.2.3 Investigative level

Investigative level was in-depth evaluation of five key hospital sites; Roscommon Hospital, Mater

Misericordiae University Hospital Dublin, Beaumont Hospital Dublin, St. James’s Hospital Dublin and St.

Luke’s Hospital Kilkenny. Investigative data collection included focus groups with staff members, semi-

structured telephone interviews with bereaved relatives and comment boxes, where appropriate. Ethical

approval was gained from three separate ethics boards nationally; Clinical Research Ethics Committee

of the Cork Teaching Hospitals (CREC), Tallaght University Hospital/St. James’s Hospital Joint Research

Ethics Committee and Research Ethics Committee HSE South East.

2.2.4 Healthcare and Support Staff

Focus groups were held with healthcare and support staff who were involved in the Design & Dignity

project or who currently use the space in their day to day work. A total of 18 staff members participated

(see Table 2 for more detail). Stakeholders were recruited by the End-of-life Care Coordinators or Clinical

Nurse Managers at each hospital site via an invitation letter. Focus groups were conducted on site and

navigated using a topic guide (see appendix 3). The purpose was to gain insight into staff perspectives

of the impact of the spaces. Each focus group was audio-recorded, and participants were asked to give

written consent prior to beginning.

2.2.5 Participants and Procedure

Table 2. Total number of participants per site

No. of participants

Hospital Staff Members (focus Group) Relatives (interviews) Comment Cards

Beaumont 4 - -

Mater 2 - 17

Roscommon 8 2 -

St. Luke’s 4 2

St. James’s8 - - -

Total 18 4 17

2.2.6 Bereaved Relatives

Semi-structured audio recorded phone interviews were held with bereaved relatives who made use of

the end-of-life care facilities (i.e. family room/mortuary/bereavement suite) in the respective hospitals.

Participants were screened via the End-of-Life Care Coordinator or Clinical Nurse Manager at each

of the five hospital sites. If the hospital had a family room, the health-care records of patients who

died on the ward where the family room was located were accessed to retrieve Next of Kin contact

details. If the hospital had a mortuary or bereavement suite, the health care records of patients who

had been reposed there were accessed to retrieve Next of Kin contact details. Once a list of potential

participants was drawn, the End-of-Life Care Coordinator or equivalent (Co-Principle Investigator) sent a

8 Unfortunately, due to circumstances outside the control of staff on the unit in St. James, staff were unable to

participate in the focus groups. Given the nature of the site, it was also deemed inappropriate to contact relatives

and/or place comment cards in the area.


11

letter of invitation, information leaflet and consent form to the bereaved relatives advising that a study

was being conducted in consultation with colleagues in UCC and if they would like to participate they

could send the consent form with their name, address and phone number and time preference to the

Principle Investigator in UCC. On receipt of consent form, the Principle Investigator in UCC arranged a

phone interview with the participant based on their time preference. Each hospital sent this letter to

approximately twenty relatives to aim to achieve a sample size of no less than 3-5 participants, taking

into account response rate and attrition. Unfortunately, only 2 sites received indications from relatives

that they wished to be interviewed and all respondents were subsequently included (n=4 relatives/

patients).

2.2.7 Comment Boxes

To reach the wider population and obtain information from “real time” a concealed and secured

comment box (and comment cards) was mounted in two of the case example spaces. Seventeen

responses were received from one site, and no responses from the second data collection site. Other

sites were deemed inappropriate to have a comment box in place, for example emergency departments

or mortuaries.

2.3 Overview of Design & Dignity Projects

This section provides a summary of each of the projects included in the evaluation.

Photographs of before and after the Design & Dignity project will highlight each of the site’s

transformation process and their key design features.

Figure 3. Overview of project types

The projects

The 18 projects included

A bereavement suite in an Emergency Department

Five mortuaries

Nine Family Rooms

Three Maternity Rooms

Family Rooms

5%

28%

17%

50%

Mortuaries

Maternity Rooms

ED Bereavement Suite


12

Firstly, the data extracted from the facility documentation will be presented followed by a summary

of each project. This will be based on the facility documentation provided by each of the teams when

originally applying for the Design & Dignity grants. Additionally, field notes and observations taken by the

researchers during site visits provide a narrative of how the spaces look and feel today.

Facility Documentation

At the request of the Irish Hospice Foundation, there was a deliberate focus on Mortuaries and Family

Rooms. Data was extracted from facility documentation of 12 sites. Details were extracted on makeup

of project team, duration of project, budget, design concepts, use of Design & Dignity guidelines, input

from family/patients, design attributes and anticipated benefits. Descriptions of the latter two areas are

integrated into the site profiles sections.

Project teams included General Hospital Managers, Director or Assistant Director of Nursing, Clinical

Prof/Clinical Staff, Risk Manager, Mortuary Manager, End-of-life care Co-Ordinator, Social Worker and

Maintenance Manager.

Project timelines varied depending on the need to change the infrastructure of a space with some

projects taking 7 weeks to complete while others took over 18 months. Most projects ran over time

taking longer than anticipated.

Project cost also varied from €30,000 to over €376,000, again depending on the type of build i.e.

structural versus aesthetics. Funding was provided by HSE Estates (& National lottery grant), the IHF and

individual hospital contributions.

Design concepts, attributes and anticipated benefits are listed below per type of build and demonstrate

the desire from project conception to ensure the new space would provide dignity, sanctuary, inclusivity

and foster staff pride.

Mortuary and Bereavement Suites

PrivacyBeaumont: “meeting needs of more than one

family”

Portinuncula: “quiet, private space for

families”

Roscommon: “private from rest of hospital”

DignityRoscommon: “to create a respectful/

dignified area for the decreased where their

loved ones can spend as long as necessary”

St. James’s “to shield families from the

business of everyday hospital life”

Sligo: “seeks to improve the dignity of death

for their patients and loved ones”

Mercy: “enhancing standard of care for

patients and increasing hospitality for their

families”

Inclusive St. James’s: “to meet multicultural beliefs of

individual patients/relatives”

Mercy: “embracing multicultural faiths”

Roscommon: “the room would be inclusive

of multinational faiths”

Sanctuary

Roscommon: “serene atmosphere gives

respect and reassurance rather than clinical

ward”

St. James’s: “ to shield families from busy

ward environments”

Mercy: “to make the mortuary a place of

“reverence & respect”

Portincula: “calm room”

Sligo: “allow for a place of death that is

reverent and respectful”


13

Family Rooms

AccessibleNenagh: “24hr access” “visible as to its whereabouts”

Connolly: “self-contained, toilets, refreshments”

Navan: “wheelchair/bed bound accessible” “light box for way finding” “exit onto garden, so you

don’t have to exit onto busy ward”

Mayo: “visible on ward” “a room that is soundproof”

Maternity Suites

PrideLimerick: “staff no longer ashamed” “less stress on staff because can accommodate

appropriately”

Privacy

Limerick: private, sensitive discussions with staff” “gentle, safe environment”

St. Luke’s: “peaceful/private for discussions of bad news; counselling”

AtmosphereLimerick: “compassionate atmosphere gives feeling you’re cared for” “soft lighting, changing

floor material, including soft furnishings and art”.

St. Luke’s, Kilkenny: “aesthetic (furnished, natural colours) to provide sense of calm”

PRIDE

Mercy“Transforming the opinion

of the mortuary”

Roscommmon“Creating culture

of care”

Sligo“Eliminating staff shame

about services”

Portiuncula“Foster sense of

ownership”

Beaumont“Confidence in facilities

that meet needs”

St. James“Create sense of pride –

not embarrassment”

Figure 4. Anticipated Benefits from Facility Documentation


14

2.3.1 Beaumont Hospital, Dublin – Family Room

Beaumont Hospital’s second project was the Family Room

upgrade in the General Intensive Care Unit (GICU). The two

adjacent relative’s rooms that existed on the ward were very

clinical and limited in terms of hospitality.

The team’s aim was to convert the two relative’s rooms into

a space where families could find comfort, relax and have

some privacy from the busy ward. Moreover, the aim was to

install refreshment facilities to allow families to prepare food,

shower and sleep over night. The project hoped to include

features such as plentiful natural light, dimmed lighting

fixtures, black out blinds for families sleeping overnight, a

kitchenette, a second room for private discussions, upgrading

the existing bathroom, TV, high quality furniture, wood

panelling and an outside garden. The team involved made

up many various disciplines – both clinical and non-clinical

making up a sub-committee of the End of Life Steering

Committee.

Today, the rooms are bright and colourful spaces. There is access to an outdoor patio area featuring

plants. High quality furniture with bright colours (purple, green) are one of the key features, with

overnight facilities on one of the rooms. Beautiful art work of flower scenes decorates the walls and

reflect the colour schemes. A kitchenette exists allowing families to make a snack or cup of tea. Other

features include a TV, dimmed lighting features and black out blinds. The space is private and tucked

away from the ward and invites a welcoming atmosphere.


15

2.3.2 Connolly Hospital, Dublin – Family Room

The Connolly Hospital team wanted a space for family

bereavement and counselling to be used by the Social

Work Department. At the time of submitting the

proposal the hospital had approximately 250 deaths

per annum. The team felt the introduction of the space

was necessary as often news was broken on the

corridors of the hospital. The proposals aim outlined a

space which allowed for patients and relatives to relax

and feel comfortable. The objective of the interior was

to create a feeling of homeliness and relaxation. Tea

making facilities would be incorporated as well as an

accessible en suite facility.

Today, the “Bluebell Room” is bright with natural light

and high ceilings. Natural light comes through glass

doors which look onto an outside patio area with

foliage and flowers. The colour schemes are light

blue, dark blue and green giving it a calming feel.

The furnishings are of high quality and adaptable to

sleepover beds. Art work of nature scenes (bluebells,

cherry blossoms) decorate the walls. On the west

wall is a kitchenette with blue and wood cabinets.

Shelves contain bereavement leaflets, toys and glass

vases. The en suite is cleverly disguised with the

blue panelling and its dimensions make it widely

accessible.


16

2.3.3 Galway University Hospital – An Seomra Ciuin Maternity Ward

The development of the private room now named An Semora Ciuin began as the team believed those

experiencing early pregnancy loss of up to 24 weeks gestation deserved a private space to process the

emotions associated with miscarriage. The room was hoped to also provide for those who have received

a terminal diagnosis to be in comfortable and dignified surroundings with their loved ones during end of

life. The team decided to convert the Clinical Nurse Manager’s office, which was in a quiet area at the

end of the ward but in proximity to the midwife’s/nurse’s station.

The aim of the room was to structurally convert the office into a bedroom and atttached ensuite

bathroom. The bedroom had to have medical equipment such as medical gas and suction equipment

to deliver safe emergency care. However, the team wanted to the room to look less clinical with design

features such as art work of sea scenes or nature art. Overall the team’s aim was for a space that was

homely, warm and peaceful.

Today, the room is a bright and homely space with beautiful art work. The muted blue colours are

calming and one walls features wallpaper which illustrates birds of Ireland.

A main design feature of the room door is the frosted shutters, which are adjustable from the outside

– so nurses can check on the patient with minimal disturbance. Structurally, the ceiling has acoustic

features which absorb echoes. The ceiling lights are adjustable as well as a light panel above the patient

bed which is also adjustable. High quality furniture which changes into a futon also features. A small

kitchenette provides tea making facilities. The ensuite contains a shower and shower chair.


17

2.3.4 Mercy University Hospital, Cork – Mortuary

At the time of application, the Mercy Hospital’s mortuary

was in a semi derelict condition. Staff, while delivering

effective care, felt dignified care was not possible when

the patient left the clinical area and was trasfered to the

mortuary. This was due to not only the lack of facilities

but the mortuary’s location, adjacent to waste disposal.

The ward environment was not an appropriate place for

families and did not allow them privacy or dedicated

time with their loved one. The team’s aim was to create

a space where families could spend time with their loved

one privately.

The team wanted the mortuary to be a space of

reverence and respect for the dead and the bereaved.

The team also wanted to improve the pathway from

hospital to mortuary.

Now the mortuary sits in a quiet and separate area from

the hospital marked by an entrance with the end-of-life

symbol. The area is decorated with plants and a water

feature, which can be heard in the mortuary giving a

soothing effect or the idea that one is close to nature.

Inside the mortuary is a small foyer with a remembrance book and bathroom facility. Off the foyer are

two viewing rooms. The main east suite features stained glass that was kept from the original build,

giving the room lots of natural light. Wood panels with shelves decorate the room and give it a polished

finish. The west suite is a smaller viewing room but increases the builds accessibility and can host two

families at one time if necessary.


18

2.3.5 Mayo University Hospital – Family Room

The staff at Mayo University Hospital believed families needed a

place for reassurance, a space to rest and feel comforted. The

proposal outlined research that reported relatives can often feel

devalued, dehumanised or disempowered when they do not receive

adequate support. The team wanted to create an area that would

be central to increase accessibility for families. An office space was

proposed as the optimal location for the renovation, existing on a

floor close to stairs, a lift and several main wards including ICU.

The team wanted a space that could offer refreshment facilities and

places to rest. Moreover, the room would be an appropriate space

to have private conversations with families rather than corridors. Overall, the proposal outlined a desire

for a space that would send a message of its commitment to improve end-of-life care to families and the

multidisciplinary team alike.

Today the space is located on the ward, marked by brightly coloured glass panels beside the door frame.

Inside is a large space with the east wall featuring windows with primary coloured panels (blue, green,

red, yellow).

Four leather couches sit beside the windows separated into two sections by a panel creating two private

areas. Within the sections the couches face one another and can be made into beds.

A TV hangs on the wall for one the sections. A kitchenette and table allow families to prepare food.

Art work of squares are painted directly onto the walls.


19

2.3.6 Mid-Western Regional Hospital, Nenagh – Family Room

The team felt it was important to introduce a space for spirituality

based on research highlighting its importance in aiding the

bereavement process. The team wanted a room for family

members where they could find privacy, quiet, comfort and peace

and was flexible to multi-denominational faiths and cultures. The

proposal outlined plans to convert a store room into the multi-

faith room.

Sleepover facilities would be incorporated into the space to cater

for families staying overnight, with 24-hour access. The location

was chosen to be at the front of the hospital – to highlight

their support for the Hospice friendly Hospitals programme

and translate a message of care for all those at end of life.

The project proposal outlined their hopes for a positive cultural

change within the hospital organisation allowing for improved end-

of-life care.

Today, the room is a bright and airy space with the colour green

and blue decorating throughout. A beautiful image of a nature

scene behind glass contributes the natural serenity of the room.

A blue couch which adapts into a bed features against a green

wall and a white couch against a white wall. The room has a

Burco boiler for tea making facilities. Leaflets for the IHF feature

on the window sill.


20

2.3.7 Mid-Western Regional Hospital, Limerick – Mortuary

The staff at MWRH Limerick wanted to renovate the walkway

from hospital to mortuary. At the time of the proposal. the

walkway was indirect and poor in appearance with families

having to walk through an unofficial smoking area littered

with cigarette butts, cups and rubbish bags. Moreover, the

mortuary itself did not meet Design & Dignity standards.

The aim of the proposal was to create an alternative walkway

for families that would be visible, easy to understand and

respectful of family’s bereavement. The mortuary was

proposed to have a store room converted into a second

Chapel of Rest, a counselling/family room and refreshment

facilities. The family room was proposed to accommodate private conversation with family with

counsellors, Gardai or chaplains. An enclosed urban garden was suggested by the team to exist inside

the build to allow individuals to see nature while in the waiting room. Designated parking facilities were

also needed.

Today the space is accessed via a direct route from the hospital with clear signposting (featuring the

end-of-life symbol) and art work. The mortuary is a modern building with parking facilities surrounding.

Stepping inside is a large open space featuring glass panels looking onto a small garden which allows

in natural light and invites nature into the space. Two green couches, a small kitchenette and art work of

leaf scenes feature. The viewing room itself is to the right of the entrance and includes 12 chairs lining

the wall with dimmed lighting. Candles, flowers and triskel symbols decorate the area. Finally, a family

room which is accessed at the west of the space through a coded door (with a frosted end-of-life symbol)

is private and removed from the space. The room is decorated with art work in abstract and muted

colours and one yellow and one green couch.


21

2.3.8 Our Lady’s Hospital, Navan – Family Room

The team wanted to update their “Day Room” into a

private, accessible and therapeutic environment. The

Day Room was situated in the centre of the hospital and

adjacent to an outside area, which the team felt could be

enhanced by creating a garden area with seating. Support

for the project was received by local management, End-

of-life care Committee, the Louth/Meath Hospital Senior

Management Team and support of Local Management.

The proposal’s aim was to use the room as a place where

staff could speak privately with families or break bad

news in an environment that supports end-of-life care. By

improving the physical space, the team hoped it would

enhance the quality of end-of-life care for patients and their families. Providing an area to connect with

nature would provide a sense of calm for families and patients at end of life.

Today the room is a private quiet space with comforting surroundings. The room is decorated with

natural wood finishing’s and high quality furniture. Artwork, lamps and dim lighting make the room

feel homely and personal. Attached to the room is an en suite toilet and a kitchenette complete with

microwave, kettle and refrigerator. The outside area has seating which is partially enclosed making it

more private.


22

2.3.9 Portiuncula Hospital, Galway – Family Room

The project proposal was to refurbish the Family/Pastoral Care

room into a private and dignified area for families of patients on

all general wards (including ICU, paediatric unit).

The staff wanted the room to be dedicated to families whose

loved ones were at end of life, to provide sleepover and

refreshment facilities. Those involved included front line staff,

senior management and a family member who was invited by

the hospital. The particular individual had experienced two

bereavements and her perspective was important to the team.

Aims outlined in the proposal included; a room which could seat

up to 12 individuals; sleepover facilities/sofa bed, a kitchenette,

natural light, colours and furnishings to provide a calm

atmosphere, TV/reading materials.

Today, the room is located beside the pastoral care room tucked

in a private corridor off the ward. The room is full of natural light

and vibrant colours. The green couches are spacious and convert

to sleepover beds. Decorated with purple cushions, the green

colour scheme mirrors nature and gives a relaxing atmosphere. Art decorates the walls depicting nature

scenes. A kitchenette provides tea making facilities. A TV and reading materials are provided.


23

2.3.10 Sligo Hospital – Mortuary

The mortuary at Sligo General Hospital provided excellent post

mortem facilities, however the facilities for families were lacking

in terms of space for grieving families and friends to congregate

and view the deceased. The Slan Project was developed by the

End-of-life care Committee and represents key stakeholders

from Sligo General Hospital and North West Hospice.

The team’s aim was to create a mortuary that provides an

atmosphere of reverence and respect for “life, death and

bereavement”. The new build hoped to improve accessibility to

the Mortuary from the main hospital and remove Portacabins

near by the Mortuary to create a sensory garden.

The new design of the mortuary now includes an accessible

route from the main hospital. The entrance of the Mortuary is

clean, modern, well signposted and features nature. Inside the

mortuary is separated into two distinct areas; one for the death

of a child, one for the death of an adult. The largest space is

dedicated to the adult mortuary and features two rooms - an

open plan space with a kitchen and attached a smaller viewing

room. The open space is bright and features a back wall of

glass doors looking onto a courtyard.

Attached to this space is a smaller viewing room with dimly lit lights, blinds on the windows and candles

enhancing the atmosphere of reverence and peace. The paediatric mortuary includes a play area for

young families, changing facilities and a small kitchenette and stove. The viewing area creates an

ambiance of peace with natural light, soft lighting and features beautiful glass artwork of butterflies and

angels.


24

2.3.11 St John’s Hospital, Limerick – Family Room

The team wanted to transform the space into a welcoming

calming environment for families to relax or rest. The aim was to

include overnight and en suite facilities. In addition to the Design

& Dignity programme, Friends of St. Johns Hospital a voluntary

fundraising group were committed to supporting the project.

Overall it was felt that a family patient focused initiative was

needed.

The team’s aim was to renovate the space into a self-contained

private Family Room with an outside space featuring patio doors

and decking area overlooking a green space. Inside the space

would feature refreshment facilities and designed in a way that

maintains privacy whilst evoking peace and quietness.

A green and orange palette is used throughout the room.

Bamboo on the patio outside is reflected in the design of the

room including the green nature themed carpet. Attention to

detail is seen in the orange ceramic lamps as well as the high-

quality material of the couches. A TV features in the room as well

as a kitchenette with microwave, fridge and kettle. An en-suite

bathroom and storage cupboard for bedding are neatly built into

the adjoining hallway making the whole space feel like a self-

contained unit.


25

2.3.12 University Maternity Hospital, Limerick – Maternity Room

The staff at the hospital wanted to renovate the then existing “Rose Room”. The Rose Room is situated

between the scan department and antenatal clinic.

Often if an abnormality is identified in an ultrasound scan or a diagnostic test, the room is used for

private and compassionate conversations with women/couples. The proposal wanted to renovate the

space to provide a message of sensitivity and compassion to women and their families when receiving

bad news.

Design ideas outlined included fresh paint, new flooring, soft lighting, new furniture and art work. The

aim was to create an atmosphere of dignity, respect and privacy in gentle surroundings.

The renovation has added depth and colour to the space. Although small, the high ceilings and natural

light lift the room. A pale pink decorates the wall giving it a calming atmosphere. Two large pieces of

artwork of nature and butterflies decorate the walls along with a painting of a rose. Two couches and a

small espresso machine are provided on a wooden linoleum floor.


26

2.4 Indicative Level Summary Analysis

The indicative level evaluation involved measuring each space in terms of physical dimensions (meters),

light (lux) and noise content (decibels). Additionally, an audit checklist on setting, appearance and

content was also completed. The following section provides an overview of measurements, audit tool

results, and researcher field notes from each of the 18 projects. See Appendix 4 for a guide to light and

noise levels recommended for a hospital setting9.

2.4.1 Mortuary measurements and audit tool results

During five site visits, seven mortuary rooms (Site A-E) were included in the indicative analysis. Of the

seven mortuary rooms visited the light (lux) measurements ranged from 2x10 – 43x10, while sounds levels

ranged from 56.6 to 76.6 decibels. Room area varied greatly from readings of 11.54m2 to 148.91m2.

From a possible score of 28, the mortuary audit assessment tools based on the Design & Dignity

Style Book Guidelines (2014) scored between 21 and 27. The best example of a mortuary that was

visited included one which was in line with the Design & Dignity Style Book Guidelines (2014). Based on

measurement data, audit assessment tools scores, and field note analysis (see 2.4.1.2) an exemplar

type mortuary should ensure the following:

Be located within the hospital and avoids clinical traffic

Have ease of access to all visitors, including those with disability and cognitive impairments

Have suitable privacy signage

Provide adequate space, with a viewing area and adjacent family room with facilities

Provide adequate parking

Have access to toilet facilities

Exclude external noise where possible

Include bariatric room where possible

Have natural light, ventilation, and suitable artwork for positive distraction

Identify as a non/multi-denominational area

For a full overview of measurement results and audit tool assessments for the mortuary see Table 3.

9 Recommendation guidelines include a maximum noise level of 45 dB(A) in hospitals (day) and 30 to 40 dB(A) in

patients’ rooms (night). Recommended level of lighting in patient care areas include 100 Lux for ward areas and 200

Lux for toilets and waiting areas.


27

Site Visit Area Light

(Lux)*

Sound

(Decibels)

Audit Tool

Score

Summary of

shortfalls

Site A – Beaumont

Hospital

Mortuary Room

09.05.2018

148.91m2 23x10 58.2 27/28

No vacant/

engaged signage

Site B – Sligo

General Hospital

Adult Mortuary

(viewing room)

Child Mortuary

(viewing room)

24.05.2018

19.86m2

13.11m2

11x10

5x10

75.9

68.3

27/28

27/28

No vacant/

engaged signage

Site C –

Roscommon

Hospital

Mortuary Room

25.05.2018

37.34m2 19x10 77.0 24/28

Minimal parking;

no ajoining family

room

Site D – Mercy

University Hospital

Mortuary 1

Mortuary 2

26.05.2018

18.47m2

11.54m2

43x10

12x10

76.6

62.4

Unavailable Unavailable

Site E – University

Hospital Limerick

Mortuary Room

23.07.2018

30.25m2 2x10 56.6 21/28 Clinical/high traffic

area; minimal

space for two

families; room

unable to maintain

room temperature;

no natural

ventilation

* Measurement was set at a medium range of 20,000 Lux. This measurement is recorded at 10 times the value of the reading

i.e x10; 1lux=1 lumen per square metre.

Table 3. Indicative measurements/audit tool scores per mortuary site


28

2.4.1.1 Mortuary field notes

Field notes were taken on the ‘walk through’ of each site and the audit team evaluated the sound

and feel of each space. Overall the Mortuary sites were described positively as feeling peaceful and

comfortable, with minimal noise except for occasional voices and white noise from appliances. See figure

5 for the most commonly used terms to describe what was felt and heard from the mortuary field notes.

Figure 5. Field note synthesis of key terms used for the mortuary sites

2.4.2 Family room

Nine family rooms (Site F-N) were also included in the indicative analysis. Light (lux) measurements

ranged from 8x10 – 114x10, while sounds levels ranged from 50.8 to 75.5 decibels. Room areas

measured between 12.32m2 to 33.01m2. A family room assessment tool (based on the Design & Dignity

Style Book Guidelines, 2014) was used to audit all sites. From a possible score of 30, the family rooms

scored between 23.5 and 30. An exemplar family room based on measurement data, audit assessment

tools scores, and field note analysis (see 2.4.2.1) has been identified as requiring:

A location within the ward setting

Be accessible and clearly signposted

Adequate space to facilitate larger families

Have high quality sleeping and refreshment facilities

Decorated to a high standard with suitable artwork for positive distraction

Include IT infrastructure

Have natural light, ventilation and access to nature where possible

Have toilet and shower room facilities

Be clean and fully serviced

Provide a homely, non-clinical, quiet, and private atmosphere

For a full overview of measurement results and audit tool assessments for the family rooms see Table 4.

What do I feel?

Serene

Peaceful

Relaxed

Spiritual

Comfortable

Breathable

Silence

Birds

Voices/Laughing

Industrial noise

Heating/Cooling appliances

Warmth

Private

Open

Closed in

Claustrophobic

What do I hear?


29


(Lux)*

Sound

(Decibels)

Audit Tool

Score

Summary of shortfalls

Site F - Mater

Misericordiae

University Hospital

Family Room

03.04.2018

15.71m2 114x10 67.0 26/10

No microwave and

toaster; TV unavailable;

No shower; light fixtures

are not controlable

Site G- Nenagh

General Hospital

Family Room

20.04.2018

13.07m2 31x10 57.7 24/30

Located off ward;

No vacant/engaged

signage; No fridge,

toaster or microwave;

minimal artwork

Site H - Our Lady’s

Hospital Navan

Family Room

04.05.2018

25.98m2 48x10 72.0Unavailable Unavailable

Site I- Connolly

Hospital

Family Room

09.05.2018

18.24m2 16x10 75.5 23.5/30

Located off ward;

Unable to accommodate

8 people; not designed

for sleepover facilities;

no TV available

Site J- Portiuncula

Hospital

Family Room

23.05.2018

13.09m2 39x10 63.4 26/30

No toilet/shower;

Unable to accommodate

8 people; light fixtures

are not controllable; No

microwave and toaster.

Site K- Mayo

University Hospital

Family Room

23.05.2018

33.01m2 53x10 50.8 24/30

No vacant/engaged

signage; Unable to

accommodate 8 people;

light fixtures are not

controllable; No toilet/

shower

Site L- Roscommon

Hospital

Family Room

25.05.2018

14.23m2 91x10 63.5 30/30 N/A

Site M -St John’s

Hospital Limerick

Family Room

23.07.2018

12.32m2 8x10 63.5 23/30

Located off ward;

No vacant/engaged

signage; Unable to

accommodate 8 people;

muted colours; not

assessible to families

at all times

Site N- University

Hospital Limerick

Family Room

23.07.2018

14.93m2 14x10 75.4 Unavailable Unavailable



Table 4. Indicative measurements/audit tool scores per family room site


30

2.4.2.1 Family room field notes

The family rooms mainly conveyed a feeling of calm, privacy, and peacefulness. Few sites were described

as claustrophobic, yet the description of noise levels varied in terms of hearing individual’s voices,

catering trollies and air vents. See Figure 6 the most commonly used terms to describe what was felt

and heard from the family room field notes.

Figure 6. Field note synthesis of key terms used to describe the family room sites

2.4.3 Bereavement suite (viewing suites and maternity units)

Within the five bereavement suites (Site O-R), the light (lux) measurements ranged from 12x10 – 69x10.

Sound ranges varied from 57.6 to 85.5 decibels. The room area measured between 6.88m2 to 26.95m2.

From the bereavement suite assessment tool (used on one site only- See Table 5) a score of 20 was

identified from a potential score of 30. Based on measurement data, audit assessment tools scores,

and field note analysis (see 2.4.2.1) an exemplar bereavement suite should facilitate the following:

Be located within the hospital and avoids clinical traffic

Have ease of access to all visitors, including those with disability and cognitive impairments

Have suitable privacy signage on all door entering room

Provide adequate space, with a viewing area and adjacent family room with facilities

Exclude external noise and soundproof where possible

Have natural light, ventilation, and suitable artwork for positive distraction

Identify as a non/multi-denominational area

Provide a non-clinical atmosphere

For a full overview of measurement results and audit tool assessments for the bereavement suites see

Table 5

What do I feel?

Peaceful

Calm

Homely

Safe

Discreet

Breathable

Quietness

Birds

Generator

Airconditioning

Catering trolley

Voices/Laughing

Outside traffic

Ward Corridor

Air vents

White noise

Relaxing views

Spacious

Warm

Private

Content

Claustrophobic

Energy

What do I hear?


31

Table 5. Indicative measurements/audit tool scores per bereavement suite site


(Lux)*

Sound

(Decibels)

Audit Tool Score


Site 0 – St. James’s

Hospital Dublin

Suite A

Suite B

09.05.2018

19.02m2

19.75m2

25x10

36x10

85.5

72.1

20/30

20/30

High clinical traffic area;

No vacant/engaged

signage; external noise;

room unable to maintain

room temperature; no

access to natural light;

worn furniture

Site P – St. Luke’s

Hospital Kilkenny

Maternity Room

28.05.2018

26.95m2 26x10 71.3 N/A N/A

Site Q – University

Maternity Hospital

Limerick

Waiting Room

23.07.2018

6.88m2 12x10 82.2 N/A N/A

Site R – Galway

University Hospital

Maternity Room

30.08.2018

15.91m2 69x10 57.6 N/A N/A



2.4.3.1 Bereavement suite field notes

From the researcher’s field note the bereavement suites were primarily described as private and

comfortable, with minimal noise except for catering trollies within the ward setting. See figure 7 for the

most commonly used terms to describe what was felt and heard from the bereavement suite field notes.

Figure 7. Field note synthesis of key terms used for the bereavement suite sites

In additional to the above data the next section presents a purposefully-developed rating scale, which

gives rooms a score of 1 – 5 for thirteen aspects of their design, including lighting, art-work, layout,

accessibility, and overall comfort, was used for each of the five cases.

What do I feel?

Private

Homely

Safe

Comfortable

Calm

Uplifted

Quiet

Voices/Laughing

Outside traffic

Catering trolley

Generators

Claustrophobic

Luxurious

Peaceful

Positive (Art

distraction)

What do I hear?


32

2.5 Five Case Studies

2.5.1 St. Luke’s Maternity Hospital – Maternity Room

From the facility documentation it was clear that the hospital team in St. Luke’s Maternity Hospital

wanted a room near the Early Pregnancy Assessment Unit. The proposal outlined the need for a space or

counselling room in which to break bad news or provide privacy to women and partners experiencing the

loss of a baby.

The proposal explained that bad news was often shared with women in the scanning room, an

environment which did not provide comfort or consideration. The team recognised the need for this

space to allow for private family time, or for blessing and baptismal ceremonies prior to burial. The

outlines for the room considered design aspects such natural colours to evoke feelings of calm, peace

and privacy.

They also felt the space needed to accommodate larger families. Today, the space is off the ward

situated in a quiet area beside the stairs. The wall in which it is located is decorated with a bluebell

scene and indicates whether the room is in use using a triskel symbol. Inside, the room is large and

contains natural light. A kitchenette and table with couches lining the wall give the room a comfortable

accessible feel.

A green couch sits in the right corner beside a beautiful stained-glass feature. The glass is lit by dimmed

lighting and depicts a sunset and water scene. Similarly, other art work is presented in small lit shelves

adding depth to the space. The wood finishes and colours give the room a calm and relaxing feeling.

St Luke’s Maternity Room makes excellent use of lighting, with multiple windows along one wall allowing

for an abundance of natural light to shine in. The choice of colours and the addition of multiple pieces of

art-work on one wall contribute to the overall peaceful feeling and relaxed atmosphere in the room. The

location of the room was well-planned and enables easy access for patients and their loved ones in an

area that is private and quiet, away from the hustle and bustle of the hospital. while also allowing easy

access to outdoors if desired. With ample space and a kitchenette, it allows women and their partners

to be surrounded by their friends and families when experiencing a pregnancy loss, should they wish.

The level of comfort could be improved with the addition of softer seating.


33

Rating

Artificial Light Fixed Adjustable Not Available

Natural Light Fixed Adjustable Not Available

Furniture Layout Flexibility10 Limited Extensive Not Available

Meal/Tea Preparation Limited Extensive Not Available

Accessibility11 Inaccessible Accessible Not Available

Art Use Random Themed Not Available

Colour Use Random Themed Not Available

Access to Nature Indirect Direct Not Available

Pathway/Signage Design Difficult Intuitive Not Available

Privacy Public Private Not Available

Acoustics Bustling Tranquil Not Available

Comfort Low High Not Available

Feel Clinical Non-Clinical Not Available

Ambiance Chaotic Peaceful Not Available

Case Study

St. Luke’s Maternity

Hospital

Maternity Room

Dra

win

g: Yvo

nne P

ennis

i and

Jim

Harr

ison, U

CC

10 Refers to ability to move furniture to create different configurations, if and when required.

11 Refers to movement and space in and around the area, including wheelchair accessibility around tables and furniture.


34

2.5.2 Mater Misericordiae University Hospital – Family Room

St. Teresa’s Ward is an acute neurological ward with 31 patient beds. Due to the acute and

complicated medical conditions on the ward, many patients receive end-of-life care support. Four

rooms on the ward are mutli occupancy accommodating six individuals at a time. Due to this, the

team felt a Family Room was necessary to support not only end of life patients, but those patients in

the multioccupancy rooms and their family members.

The Family Room at the time of the proposal was tired and worn and was sometimes used for

storing medical equipment. The room was co-funded by a Design & Dignity grant and fundraising by

staff and the Mater Foundation. The teams aim was to design the room and decorate in such a way

that would lift individual’s mood and enhance their care experience. Features outlined in the proposal

included; a kitchenette, a wall mounted TV, three chairs/settees around a coffee table; a family

room sign which was informal in nature to indicate the room is open to all and is a comfortable space.

Today, the room is clearly signposted on the ward and leads you into a quiet comfortable space. In the

room are three high quality couches in red and beige providing seating for eight people, one of which is

a sofa bed allowing a family member stay overnight on the ward if their relative is seriously ill or dying.

There is a kitchenette with tea coffee making facilities.

Views outside the window fill the room with natural light. Art work decorates the walls depicting scenes

of hot air balloons, birds and nature. The bright wall colours of the space and the use of wood effect

flooring and artwork lift the room and give the room a non-clinical feel.

The Mater family room is filled with natural light, and offers families a bright and airy space where they

can relax and make a cup of tea or coffee away from the main hospital ward. It makes good use of

colours and the view of the outdoors makes it a nice, relaxing space. The room is located in the heart

of the ward so that it is accessible to patients and their families. The family room has a door sign to

indicate ‘in use’ to facilitate privacy when required. The furniture in the room is firm but functional and

there is little scope to change its layout in the current space available. As such, it may not be suited to

larger groups of more than eight people.


35

Rating



Furniture Layout Flexibility Limited Extensive Not Available


Accessibility Inaccessible Accessible Not Available










Case Study

Mater Misericordiae University Hospital

Family Room

Drawing: Yvonne Pennisi and Jim Harrison, UCC


36

2.5.3 Beaumont Hospital – Mortuary

At the time when Beaumont Hospital applied for the Design & Dignity grant, the hospital’s mortuary

represented 3% of the annual statistics for deaths in Ireland (approximately 1,000 deaths per year).

The mortuary urgently needed a second viewing room to expand the services as often the mortuary

facilitated several removals a day.

No facilities existed for families such as a space for formal identification or ceremonies to take place.

Parking was an issue and families often had to park in another facility ten minutes walk away. Overall,

the team wanted a serene, intimate family space that would provide for the requirements of the

bereaved.

After the Design & Dignity project, the mortuary has been renovated into an open space with great

amounts of natural light. The large family area is open and comforting, with green armchairs to sit and

gather. A garden patio area has been built onto the east side of the room, accessed by sliding doors, to

allow families to go into nature. From the family area is the main viewing room, also accessed by hinged

doors and lit by a large sky light giving the room a bright, airy feel. Blue glass art work decorates all

three walls in the viewing area.

A second family room and viewing area is built onto the west side of the build. Again, this area is bright

airy and features high quality furniture (green) and the blue glass artwork – continuing the design

throughout the build

The design of the Beaumont Hospital Mortuary allows for huge amounts of natural light to shine in,

which together with the carefully-selected pieces of art and paint colours and the views of the outdoors,

provides a calm, serene setting for loved ones. Situated away from the main hospital the space is quiet

and offers loved ones privacy at a very difficult time. It is easily accessible, with sufficient space for

larger groups to come together. The addition of more comfortable seating increases the overall comfort

of the area.


37

Rating















Case Study

Beaumont HospitalMortuary



38

2.5.4 St. James’s Hospital Emergency Department – Bereavement Suite

At the time of the grant application, the Emergency Department (ED) of St. James’s had over 150 deaths

per year. The ED was lacking in private areas for families to view their loved one. The family room and

viewing room were two separate spaces and families would have to walk down a busy corridor to access

both. The team wanted to create a private space to shield families from the busy hospital atmosphere.

They proposed the build of two family/viewing rooms. Staff felt embarrassed of the space and believed a

new space was pivotal to help enhance staff support of families during a traumatic time of their lives.

Today, the two Bereavement suites are separate spaces off the busy ward. Both suites contain a

relative’s room and viewing area separated by wooden sliding doors that can be pulled back expanding

the space if necessary. Each relative’s room contains a black leather couch and armchair and three

stained glass art works that are reminiscent of a sea scape in blues and greens.

Inside the viewing area is a trolly with a purple drape and white end-of-life symbol. Beside the trolley is a

cabinet decorated with flowers and candles.

The Bereavement Suite at St. James’s Hospital ED offers some privacy and a comfortable space away

from the ED for loved ones going through bereavement. There is good use of artwork, but the room lacks

natural light. However, to ensure privacy in bereavement suite designs it may not be appropriate to have

windows, unless frosted and or elevated. Noise can be heard from the ED, and this combined with the

artificial lighting and choice of colours creates a space that still feels quite clinical and not very relaxing.

Improved lighting and use of brighter colours, as well as the provision of more comfortable non black

leather seating options would make this a more welcoming space for families. A kitchenette would also

be a welcome addition.


39

Rating


Natural Light12 Fixed Adjustable Not Available


Meal/Tea Preparation13 Limited Extensive Not Available




Access to Nature14 Indirect Direct Not Available







Case Study

James’s Hospital Emergency Department

Bereavement Suite

Dra

win

g: Yvo

nne P

ennis

i and J

im H

arr

ison, U

CC

12 Difficult to have windows as it may not be appropraite unless frosted or elevated

13 Catering staff provide tea and coffee to families, if and when required

14 Refers to indoor plants or direct access to an outdoor area


40

2.5.5 Roscommon Hospital – Mortuary

The Mortuary in Roscommon is designated to the entire county and is therefore often used for sudden

deaths in the community. In this circumstance, families accompany their loved ones to the mortuary. The

team felt a dignified space was pivotal to support families during their shock and grief at this time. The

team also wanted to space to be used for individuals who pass away in the hospital.

At the time of the proposal the viewing room was accessed directly from the environment and was of

poor aesthetic quality. The team wanted a space that would create an atmosphere of reverence and

respect by using adjustable lighting, natural light and art work. A toilet on site would be built and sign

posting would be clear.

Today, the space is a private area separate from the hospital. A small corridor featuring a sky light

separates you from the viewing room and gives you access to a bathroom. Within the viewing room, the

main feature is the stained-glass reflecting colours of purples, blues and greens. The purple is featured

throughout the room seen in the couch, the viewing table and the end-of-life symbol framed on a shelf.

The soft lighting and wood floors give it a non-clinical look and respectful atmosphere. Sign posts are

used to show if the room is in use.

Roscommon mortuary scored well in certain areas in terms of

star rating. Accessibility and to the area and the full access to

natural light was a bonus. The colour scheme was beautifully

themed and there was a feeling of privacy and peace in the

space. While there was a green area outside the mortuary

this was a public and open space. Tea making facilities were

also lacking.


41

Rating















Case Study

Roscommon HospitalMortuary



42

2.6 Overarching Themes

2.6.1 Investigative Level – Staff Focus Groups

For the investigative level, four staff focus groups were conducted in sites identified by the Irish Hospice

Foundation, based on type of project and geographical spread. As the analysis was a deductive thematic

analysis, the themes are partially informed by the topic guide which was developed to address the key

objectives of this evaluation.

Four overarching themes were identified from the focus groups and these are reflective of the evaluation

objectives; accessibility, design feature, meaningful change and purpose. These themes were composed

of a number of subthemes and codes (See appendix 5).

At the commencement of each focus group, staff were asked to describe in one word the new space that

was created as a result of the Design & Dignity programme.

2.6.1.1 Accessibility

Accessibility to the space was a key feature of the focus group discussions. Within this there were three

subthemes and these related to assessing who gets to use the room, security measures and the use

of signage. With regards the family rooms there appeared to be an informal triage system used by staff

on the wards to assess which family the room should be prioritised for when more than two patients

are nearing the end of life. This system took into account the age of the core family members, distance

to travel and the assessment of which patient was the most acutely unwell. Staff noted that while the

space was in constant demand there were never issues with dual use as this was usually managed

informally, using the criteria outlined and also a pragmatic ‘first come, first serve’ approach. The use of a

sign in sheet was discouraged as staff felt it created a sense of surveillance and conflicted with the idea

of user-friendliness.

The use of occupied/unoccupied sign outside the door was favoured over a lock on the door; both from

a health and safety perspective and negating the need for families to remember to return keys to staff,

reducing the risk of keys going missing. Furthermore, there was a fear that if a room could be locked

from the inside then this would constitute a ‘risk’, if evacuation of the facility was required or if an

incident occurred in the room and it was inaccessible from the outside. Nonetheless, it was found that

some occupied signs were broken and staff in some areas felt that a family should be able to lock the

door at night to ensure privacy.

Words used to describe the spaces by staff members


43

Finally, finding the room and proper use of signage

was discussed among the focus groups. Some

rooms were located in the centre of the ward

and were easily accessible, with a large wall sign

stating, ‘family room’.

Others were less easy to locate and often required

staff to escort family to the room, through a

series of corridors. There were a number of trade-

offs considered when discussing the location.

For example, having the family room on the ward

allowed family to be near but yet relocate from the

bed-side to a non-clinical space, if even only for

a few minutes, to reflect and have a cup of tea.

However, ward sounds such as trolleys, clinical

smells and staff chatter were still present.

Less accessible rooms located off the ward created a better sense of calm, oasis and serenity, and were

more conducive to facilitating family wishing to stay overnight or for longer periods. There were strong

arguments for both types of family rooms in the one hospital setting.

“Signing in and out creates surveillance around their use– And you don’t want them to feel like that because they might not want you to know when they’re coming and going” Staff Member

“That the room is open and accessible, you know, that it’s not under lock and key, that people can feel they can go in and out – and obviously you do have an “in use” sign on the door because there are times when people can’t go in, you know when there is a family meeting with a patient or staff meeting with a patient and family and you don’t want people interrupting those sensitive times. And that’s worked really well having that sign on the door so that people know “Oh yeah – don’t disturb”. Staff Member


44

2.6.1.2 Design Features

During the focus groups staff were asked which design feature they liked the most and that had the

greatest impact. Conversely, they were also asked to describe and discuss fetures that they liked

the least or would change if they could do it all again. Reflective of the literature, most agreed that

artwork was a key design feature to get right and one that had real impact. This was closely followed by

themed colour use, a self-contained area and sense of space. Finally, a core feature was to create an

environment that had a non-clinical, homely feel.

Artwork

Across the sites artwork varied greatly,

nonetheless staff all agreed that it was one of the

features that had the potential to create a positive

memory for families in a not so positive situation.

Vibrant artwork, which was abstract in style,

was described as most appealing. All staff were

hugely complimentary of the local and national

artist/designers, with many stating that the

art work created a ‘wow’ factor in the room,

exemplifying a facilitator of positive distraction.

Non-denominational art was also recommended

in order to portray organisational support for

inclusivity

Themed Colour Scheme

From the focus group discussions, it was evident

that much debate and time went in to deciding on

the type of colours to use within the space. The

design guide published by the IHF was found to

be very useful in determining colours with many

opting for lime green and purple colours palette.

These colours were described as having a calming

effect and were bright and fresh. Furthermore,

some staff felt that vibrant colours helped to

distinguish between the typical hospital ward

colour of white and that purple/lime paint added

to a warm and welcoming feel.

Non-Clinical Environment

The use of non-white paint and wooden effect

flooring also supported the desired ambience of a

non-clinical space. Staff vocalised that soft quality

furnishings, TV, kitchenette and artwork all led to

the homely feel. It was essential that no clinical

devices or equipment such as oxygen ports were

on the wall, to further create an environment that

was distinct to the ward/bed side area.

Sense of Space

Access to nature, natural light and a roomy area

to move, containing various types of furniture, was

described as creating the optimum environment.

Low ceilings, large furniture and a feeling of clutter

was discouraged and represented much of what

was previously available for families. Staff agreed

that the advice and guidance provided by the IHF

We had lots of catholic imagery all over the mortuary. Now, the glass is abstract. So it can be interpreted… Staff Member

I would often just go in and look at the picture and there is something about the high-tech clinical unit and then coming into a very family, homely space. And they are side by side… Staff Member


45

architect was crucial to ensuring that maximum

access to natural light was obtained and planned

for in the redesign. The use of indoor plants also

allowed for in direct access to nature where it

wasn’t possible to walk outside, particularly if the

room was located in the heart of a multi-storey

building. All of these aspects created a sense of

space.

Self-Contained

A positive design feature of family rooms or

bereavements suites was the fact that they were

largely self-contained. Most had sleeping facilities

and a kitchenette. The ability to make a cup of tea

was fed back to staff as a ‘godsend’ and fostered

independence. This of course was followed by the

need to ensure that rooms were maintained by

household staff and fully serviced daily to ensure

stocks of milk, coffee etc. did not deplete.

Some spaces also had shower facilities

connected to the family room, while others were

reliant on shared toilet facilities only. Many staff

from sites with the latter facilities articulated

that if they had a bigger budget and access to

more space they ideally would have integrated

an ensuite type section to the family room, thus

creating a space almost like a ‘mini apartment’.

Roscommon family room was an excellent

example of self-containment, as depicted in the

above sketch.

Functionality, homely. It’s what people need, they need to charge their phones, they need to be able to eat and drink, rest. Gather. Staff Member

“I think the amount of openness now with the big windows, big patio area and just the fact that it opens a whole area up, allows light in you know so it’s kind of a nice feel”. Staff Member

“I think the brightness of the room; it’s a very bright room. In winter when you come in it just seems kind of – there’s a warmth in the room. Even though it’s a sad experience still there’s warmth when you come in, I don’t know is it the lighting maybe as well? The lights coming in, naturally light coming in, helps”. Staff Member


46

Impact on staff

Seven codes were generated under this theme

and associated themes. These ranged from

reducing embarrassment to enabling open

conversations about dying in acute care. Staff

pride in the Design & Dignity programme and the

resulting space in their workplace were palpable

across all focus groups. Interestingly staff also

reported that the space demonstrated to patients,

family and the broader healthcare team that there

was a corporate commitment to end-of-life care.

An increase in staff morale was also evident

from the interviews. Most projects were part

funded and although it was an initial challenge

to convince senior management, in some

instances, to relinquish a private room, when this

commitment was made it sent a clear message,

that end-of-life care, in acute care, matters. This

was seen as a very positive message to portray

and helped staff to feel that further applications

for end of life spaces would be supported, where

possible.

2.6.1.3 Meaningful Change

Central to each focus group discussion was the impact of the Design & Dignity project on family, staff

and culture of care. These subthemes are reflective of the secondary objectives of the evaluation.

Staff Pride

Reduce

embarrasment

Open

conversations

Spend more time

with family

An examplar to

show to visitors

Generate hospital

wide interest in

private spaces

Corporate

commitment to

end-of-life care

Figure 8. Impact on staff

“When I’m talking about the D&D projects that I’ve been involved in I would often describe them as the things that I’m most proud of in my career because they are tangible as well, something really – you might do a policy and it’s sitting there and people aren’t following it and you get frustrated. But you can walk – I get a sense of pride every time I bring a group into the mortuary” Staff Member


47

The new space also enabled staff to spend more

time with family without interruptions. Prior to

the refurbishment many staff would have brief

conversations in the nurses’ station or on the

corridor where disturbances such as call bells and

the phone ringing were plentiful. Now they had a

space where they could listen, think and talk in a

calm, supportive environment with relatives at a

very vulnerable and sad time in their lives.

Impact on Family

Staff in the focus groups were asked to reflect

on the impact that the project may have had

on family that used the space. Many recalled

feedback they received, all of which was extremely

positive. Families had identified to staff that the

room had given them something positive to look

back on. The space was described as somewhere

to escape to following long vigils at their loved

ones’ bed side. The seclusion and serenity

that the room offered to family was relayed by

staff, with many commenting on the fact that

family were ‘never too far away’, if the patient

deteriorated rapidly, unlike before, where family

would have gone home to have a shower or to get

some sleep, often missing the moment that their

loved one passed away.

Impact on Culture of Care

The impact that the projects had on the culture of

the organisation and how care at end of life was

valued by all clearly emerged as important themes

from all five discussions with staff.

Staff also spoke about the desire of families to

give something back. Families gave donations

of microwaves, hairdryers, toiletries etc. in

appreciation for having this space and in the

hope that others would benefit from its existence.

Some felt it should be a protected space and

wanted to contribute to ensure the sustainability

of high standards.

Summary

The projects were described as symbolic

of compassion and demonstrated that the

organisation valued the experience of those

grieving, something that only hospices were

previously adept at. Acute care is traditionally

associated with a culture of cure despite over

40% of deaths occurring in our public hospitals.

However, the Design & Dignity programme not

only transformed physical spaces but, according

to staff, transformed end-of-life care and has

been the catalyst for dignified care in acute care

settings. Of great significance to staff was also

the reduction in what they termed ‘corridor care’

or ‘corridor conversations’. This type of practice

often left staff feeling uncompassionate and was

at odds with their desire to provide privacy, dignity

and confidentiality. The new spaces have ensured

that these principles are no longer aspirational

but rather rooted in the culture of end-of-life care.

To have a place rather than leaving them on a corridor to wait for a consultant or – you can bring them in here for them to let their grief out, let their tears out. You know to give them the time. And there is no pressure on them – they can stay in the room for as long as they want.” Staff Member

“The space is very important but it’s the philosophy of valuing this experience and acknowledging the importance of this death that is happening that is really important. The environment helps that. There is no doubt about that. Having a space to bring people and have a cup of tea – I mean it’s so basic. But yet so important, it’s everything.” Staff Member


48

2.6.1.4 Purpose

As part of the evaluation we were interested in determining if the rooms were being used for their

intended purpose and indeed what purpose they were serving. Three subthemes emerged reflecting the

use of the rooms.

The primary function of the family rooms was to provide a space for family to come together and have

protected time to talk, plan and make decisions regarding end of life and after death. Not only did the

room provide a place for families to meet with one another, it also facilitated meetings between and

with the healthcare team and often the patient. Owing to the private setting the room was described by

staff as a suitable environment for having difficult conversations, including breaking bad news. None of

the rooms were described as multi-purpose and were policed and protected by staff on the wards. Staff

discussed how initially when the rooms were built, members of the multidisciplinary team (MDT) needed

to be educated on their use, as sometimes it was used for education or taking phone calls etc. Once

everyone saw the value of protecting rooms for end of life matters they were never used for storage or

staff respite and soon became a very sacred place.

2.6.2 Investigative Level – Family and Patient Feedback

For the investigative level, feedback was received from

16 relatives and 3 patients who had used a Design &

Dignity space, specifically a family room or maternity

bereavement suite. Feedback was given either in

real time, using a comment card left in the room,

or after the death of a loved one via telephone or

face-to-face interview with a member of the research

team. An overview of the comment box responses

can be reviewed in Appendix 6. Impact on the family

and positive design features were the core themes

to emerge. Within these a number of subthemes are

described – Figure 9.

• Dedicated space for difficult conversations and

breaking bad news

• Space for open disclosure

• Place to plan for end-of-life and after death

• Space for family and patients to sit and talk

• A quiet place for patients to go

• A place for family to rest and sleep

• A place to provide refreshments to family

Meetings

• Family meetings

• Not ward meetings

• MDT use

• Not multi-purpose only end-of-life matters

Dedicated Space

for Refuge

Respecting Dignity

and Privacy


49

Impact on Family

The positive impact on family was clearly evident

from the interviews and comment cards left

by family members. The family rooms provided

a private space, created a positive memory,

supported uninterrupted time, facilitated a break

from the bed-side and reduced the feeling of being

in the way. These subthemes will be described

sequentially.

Provided a peaceful, protected space

Many described the family room as a

protected space to support and facilitate

reflection, a place to be with family, a place

to be alone and a room to bring visitors.

The privacy and ability to think was seen as

invaluable. Participants commented on how

the space provided somewhere to host family

meetings, talk, sleep, regroup and freshen up.

Other participants noted that they didn’t really

have expectations and were surprised and

pleased to find that this space existed. Once

they saw the benefits of using the space

participants questioned why a hospital would

not have an end of life space for patient and

families to use. It was described as innovative

yet essential.

The seclusion that the room brought was

something that families reflected on, noting

that without the space they would have to go

outside the building for a walk or sit in their

car to get some peace.

Supported private, uninterrupted time

Owing to the busyness of a hospital it was

important for family to feel they had a place

where they were uninterrupted by other

families or staff. Many revered the fact that

they were the sole users of the family room.

Some stated that they would not like the idea

of competing for time and private space in

the room and therefore proposed that there

should be a number of family rooms in each

hospital.

Furthermore, a suggestion was made to have

a more public type family room off the ward

where you could sit and relax, make tea but

also interact with families going through the

same thing. This could be in addition to a

number of private family rooms with sole

occupancy encouraged, to sleep and have

privacy as a family unit. Some described

themselves as being lucky if they were the

only family who needed the room.

“One of our principles for the family room in the hospital is that-it’s a room for patients and families and the use is around meeting a patient and a family or meeting with a family but not necessarily for any other purpose other than that”. Staff Member

“I think it was just a space that allowed us to kind of centre ourselves or to take a breath and just you know over time as well like ourselves as well come to terms with the situation.” Relative

“There were occasions where there were other people there as it happens most of the time when we were there weren’t other people using it so that was nice from our point of view naturally we were pleased with that” Relative

“It was like an oasis of calm to be honest. In the middle of these emotions and sickness, doctors and nurses, which is all an integral part of the day, you know it’s a busy busy hospital. Here is this place that you could just close the door and kind of say “oh peace” Relative


50

Facilitated a break from the bedside &

reduced the feeling of being in the way

Families described how they had a huge

desire to be by the bedside of their loved one,

however this was not sustainable over long

periods of time. Many stated that the room

allowed them to take a break and switch

off momentarily, away from the bedside in

a separate environment. Simple things like

watching TV or listening to the radio helped

them cope with the situation, and still feel

they were present.

Not only did it facilitate a break from the

bedside it also helped to form positive

memories in a not so positive situation.

One person described that when she looked

back on the death of her loved one she

remembered the family room as being a

positive memory during a very emotionally

bad time. This positive memory was created

from the different feelings and smells that the

family room brought compared to the bedside.

The room was described as providing dignity

to family members.

All too often families find themselves on the

corridors of wards while their loved ones are

receiving care and treatments from healthcare

professionals. The room ensured that family

had somewhere to go during this time and

helped them to feel less in the way of trolleys

and staff in a busy clinical setting.

Enabled family to be present

The family room was described as

convenient and supported basic needs

such as sleeping, eating/drinking and

personal cleansing and dressing. As

family didn’t have to leave the hospital

grounds to fulfil these needs it meant

they could be present with their loved

one. Many stated that they couldn’t have

functioned without it.

“It probably got us out of their way a little bit when they needed to come in and do em, you know what they needed to do with Mom because we could just go down when the medical staff or the nurses or the carers came in instead of having to stand around in the corridors waiting for them to finish we could just go down and use that time to sit and to talk with each other” Relative

“It was brilliant. There was more dignity to it as well. You weren’t all standing in a corridor you know and disturbing other people as well? It was just… you could come away.” Relative

“You know the way you don’t want to leave the hospital – you don’t want to go too far away but at the same time like you needed a break? Or you just needed to get out to clear your head for a few minutes it was just somewhere to go… just where you could you know go, but yet you were near. You could be back in a minute if you needed to be.” Relative

“It actually went beyond our expectations and I’m not trying to make it sound glorified but many – it really meant an awful lot. We wouldn’t have managed without it. You couldn’t. We wouldn’t have all been allowed stay. That wouldn’t have been possible or fair. It allowed us to stay... it allowed us to be with him till the end.” Relative


51

DESIGN FEATURES

Non-clinical, homely feel

It is undisputed that a non-clinical environment

is desirable for a family room, as this allows

family to separate from the bedside and busy

ward to a place they can gather their thoughts

and take a break. Further enhancing the non-

clinical feel was having a room away from the

ward or sound proofed from the typical clinical

noises such as bleeps, monitor alarms,

phones and trolleys.

One family member stated that the room

thoughtfully used the Design & Dignity

scheme, showing value for money while

remaining welcoming. Indicators of family

satisfaction with the room were cleanliness,

it being aesthetically pleasing, and fully

serviced. The room was also described by

some as a nice place to return to with a

familiar and comforting smell, and a room

that resonated feelings of peace and serenity.

Little things like having a plant or luxury

toiletries were seen as tasteful and created a

feeling of home not a hospital.

Accessibility

Access to the rooms and being told that the

room exists was very important. One family

member noted that they only found the room

by chance when walking down the corridor.

Others complimented the signage used in the

space, stating that it was easy to find once

you were shown by staff the first time. Another

family member said they had been to the

hospital previously in a similar circumstance

and not offered the room, which made

them question room allocation and usage.

Participants felt that room allocation needed

to be transparent.

Artwork & themed colour

Findings from the staff focus group are echoed

by relatives who stated that the artwork

created a positive distraction. Relatives were

highly complimentary of the glass work that

helped to facilitate an environment of serenity.

Family distinctly remembered the use of nice

colours with some commenting specifically on

the green and purple, which were described as

pretty and earthly, helping one feel connected

to nature. The use of this colour palette

appeared to have a calming effect and was

distinct from the standard white walls on the

wards, further supporting the non-clinical feel,

described earlier.

“The dynamic or the feeling of the room was very different to your standard hospital feeling where you can kind of almost you know the corridors, the wards are more clinical, the room was I guess more homely”. Relative

“Because the hospital is quite old and it’s quite clinical – it’s a hospital and some of the rooms and places in there can feel a bit like a prison ward – not that I’ve been to prison – but like it can be, it’s kind of a horrible hospital. I do remember thinking “Wow this is nice”. “This is a nice room in the hospital” Patient


52

Kitchenette

The kitchenette was labelled as a positive

design feature by all. The convenience of

being able to make your own cup of tea was

described as something that provided great

solace and negated the need for family to

leave the hospital to get refreshments or

sit in a noisy canteen within the hospital.

Furthermore, it reduced cost for families,

particularly if they were there for a number of

days.

Furniture and layout

Comfortable seats were described as

essential and something that was appreciated

by families who used the space. The spacious

area was compared favourably to sitting at

the side of a bed or on a chair in the corridor.

The balance between the number of seats/

couches versus large floor space to pace/walk

was notably important to family members. The

rooms were described as having a practical

layout with proportionate furniture. A number

of suggestions included having a recliner and

higher seats for impaired visitors. To improve

the homely feel the inclusion of cushions was

also mentioned.

Functional distractions

Most families mentioned the use of

electronics in the context of a positive

distraction. Where a TV was not present

families voiced the need for a TV to be

included going forward. Other devices such as

a radio was described as important to help

distract from negative internal discourse.

Having large windows to look out of also acted

as a source of distraction. For some, knowing

that the world was carrying on outside created

feelings of sadness, but for others it was a

reminder that life goes on.

“Convenience was something that was really important, just being able to make a cup of tea. The fact that it was a space that was quiet actually that was something that I found very good about it, just being able to go someplace that was yes physically still very close to where my mother was so that we could be back up there in a few seconds if we needed to…” Relative

Figure 9. Family and Patient Perspectives

• Provided a peaceful, protected space

• Supported private, uninterrupted time

• Facilitated a break from the bedside and

reduced feeling of being in the way

• Enabled family to be present

Impact on Family

• Non-clinical homely feel

• Accessibility

• Artwork and themed colour

• Kitchenette

• Furniture and layout

• Functional Distraction

DesignFeatures


53

Chapter 3: Recommendations

& Reflections


54

3.1 Key Challenges and Lessons Learned

3.1.1 Project Level Challenges:

All staff reported on the challenges they encountered at the initial stages of the project design and

development. The most frequently reported challenge was securing funding, this was closely followed by

time related issues and adhering to hospital policies.

Lead in time for each project varied across the sites from 18 months to over 2 years. The most time-

consuming aspects were setting up a project committee or team, applying for the Design & Dignity grant

and appointing a contractor.

Liaising with contractors was also noted to be difficult during the planning stages. This was further

compounded if the hospital team lacked building expertise or if there was a fluctuation in the project

committee membership

Changing the function of the room by moving from a multi-purpose room to a protected family room

required numerous information sessions with staff in the area, to ensure the purpose and use of the

space was adhered to and creating ‘conscious awareness’ for staff that end-of-life matters.

Securing funding both from hospital management and the Design & Dignity grant was time consuming

and challenging. Most sites also sourced funding from several other sources such as donors or

fundraising events. These activities were sometimes met with negative attitudes, as other areas in the

hospital were seen as more important or other competing fundraising was taking place for vital medical

equipment. The lack of capital budget for family rooms or bereavement suites was described as a

contributing factor to the slow roll out of similar projects hospital wide.

Changing the

Function of the

Space

Adhering to

Hospital

Guidelines/Policies

Liasing with

Building

Contracters

Securing

Corporate

Commitment

Securing

Funding

Long Lead Time

to Completion

Design & Dignity

Project

Challenges

Figure 10. Project Challenges


55

Securing corporate commitment and convincing hospital management to give up space and sometimes

a private room with a guaranteed revenue stream, was difficult and required numerous meetings and

board presentations. Inextricably linked to this was committing to support personnel to undertake this

project as part of their role in the hospital.

Adhering to infection control and health and safety policies was a challenge for staff, particularly when

the desire was to create a homely non-clinical feel. For example, soft furnishings and floor type required

negotiation, moving from standard hospital lino to wooden/laminate flooring.

3.1.2 Project Level Facilitators:

There were six main facilitators identified at project planning phase, leading to a successful project.

These included:

1. Establishment of multi-disciplinary committee where members are involved throughout the

process from project inception to launch

2. Incorporating Design & Dignity Style Guidelines and principles from the start

3. Use of an outside architect with an interest in evidence-based healthcare design

4. Involvement of all staff in naming the room to support ownership and hospital wide interest in

the space

5. Attending presentations from other Design & Dignity projects facilitated by the IHF or

conducting site visits to view completed project

6. Promoting organisational philosophy of end-of-life care

3.2 Recommendations

Pages 56-59 provides a comprehensive account per project type, followed by organisation level for

Design & Dignity projects going forward. Recommendations have been informed by site visits, focus

groups, evidence-based literature and relative’s feedback. The following are recommendations for

sustained standards in practice and/or areas for future consideration and are mostly in addition to

those contained in the Design & Dignity Style Guide (Irish Hospice Foundation, 2014).


56

3.2.1 Project Type Level: Mortuary, Family Rooms and Bereavement Suites

Future Mortuary Design

As part of new builds it is recommended that mortuaries are located at the centre of the

hospital site with a directly linked corridor, so families don’t have to go outside to enter the

mortuary.

When planning the location of a mortuary consideration should be given to a location which

is not adjacent to the hospital’s rubbish processing area or supplies depot, to ensure a

respectful passage.

Direct access to nature with an outdoor seating area should be considered in the planning

phase.

A hangout area for younger children or teenagers with electronic charging facilities and age-

appropriate seating is recommended.

Where possible a large porch outside the mortuary should be considered to protect

mourners from various weather conditions.

Mortuaries should provide for all customs and rituals where possible and multi-

denominational ‘packs’ should be easily accessible at each site.

Protected parking spaces are essential, and provision should be made to support numerous

spaces during times of funeral services.

Clear signage for the mortuary needs to be in place from the main entrance to the hospital.


57

Family Room Recommendations

Type of family room

Development of two types of family room in acute care is recommended

One at the heart of each ward for families that need a break from the bedside but which are

still close enough if there is a change in their loved ones’ condition. Also, this room could

facilitate family meetings with medical and allied healthcare staff, and permit tea/coffee

making facilities.

A second larger room off the ward is recommended, but still within the hospital building,

that is fully-serviced and self-contained for families to stay over, have larger family meetings,

shower and have sustenance. A centrally located larger rooms also facilitates a family to

meet other families going through something similar.

Sources of distraction

Within the family room there is a need to provide sources of positive distraction including a

TV, selection of music with radio/CD equipment and books.

Artwork was described as one of the top features and it is recommended that artwork be

maintained and updated to align to new trends over time.

Fish tanks could also be integrated into new projects together with different types of plants/

flowers of a non-artificial nature.

Future proofing

Situated within the technology era it is important to ensure that the rooms have good Wi-Fi

that supports browsing and the ability to use video conferencing such as Skype or Zoom to

connect to family abroad.

The integration of docking stations and charging units for electronic devices is also

recommended.

Soft furnishings, accessories and utensils

Fold-up chairs or recliners for overnight stay in additional to couch beds.

Age-appropriate seating is required, as some couch beds can be very deep for older persons

or people with a disability, therefore armchairs or higher seating is recommended.

Beanbags or bespoke seats for children and teenagers to lounge and relax on are also

recommended.


58

Family Room Recommendations Continued

The seating layout needs to be balanced with maintaining a sense of space and

accessibility.

All furniture needs to be durable, functional, yet comfortable and in line with the Design &

Dignity Style Guide.

Non-fixed lighting, such as reading lamps, should be assessed for fire risk and positioned

away from leather seating and accessories.

Where tea and coffee making facilities are available there should be domestic crockery

available to create a homely feel. Styrofoam cups and plastic cutlery are discouraged.

Accessories such as cushions and non-slip floor rugs/mats are recommended to enhance

the homely feel and soften acoustics of the room.

Battery operated candles or aroma diffusers should be available to create a calming

atmosphere and a relaxing fragrant non-clinical feel to the environment.

Fully serviced area

Rooms should be part of the daily rota for household staff, ensuring plentiful supply of

freshly stocked linen and refreshments. Daily cleaning of the fridge, floors, counters and

bathroom facilities is recommended.

Cleaning products should be stocked in the kitchenette so that families have the option to

clean up after they use crockery etc. These should be stored in a high cupboard and out of

risk/sight of young children – in line with hospital policy.

Electrical appliances such as a microwave, toaster, fridge and kettle are recommended as

essential features in family rooms but their maintenance should be checked on a routine

basis to ensure they are functioning properly and do not pose a risk.

Bathroom/shower areas should have personal amenities/products such as toothpaste,

shower gel and shampoo freely available.


59

Bereavement Suites in Emergency Departments

Many of the recommendations pertinent to the family room are transferable to bereavements suites,

with the addition of the follow three areas:

Bereavement Suites in Emergency Departments should be located off the main ward to

ensure that family don’t have to walk through a busy clinical area.

Direct access to outdoor space with additional seating is advisable.

A large space for family to gather and have refreshments with self-contained bathroom

facilities should be directly adjacent to a viewing area.

3.2.2 Organisational Level

Generic to all projects, regardless of project type, there are several recommendations proposed.

Establishment of a multi-disciplinary, end-of-life care committee whose terms of reference

include the financial sustainability of Design & Dignity spaces by setting up a fundraising

stream to support the maintenance and replacement of soft furnishing and aesthetic

aspects of the rooms such as painting, furniture and electrical items. The function of the

committee would also be to support staff in applying for future Design & Dignity grants

and seeking corporate support. Furthermore, the committee could assess/triage internal

proposals from staff and assist in prioritising areas that require improvement to deliver

dignified end-of-life care.

Development and implementation of a staff education programme on the use of family

rooms and the Design & Dignity grant scheme to create awareness, ownership and facilitate

a culture that protects and promotes end-of-life care spaces should be considered.

Publicity/awareness raising campaign to raise funds for additional projects.

Continuation and further expansion of the Design & Dignity programme as this is a major

catalyst for change, as one project can have a rippling effect across the entire organisation.

Central to successful projects is early consultation with an architect who specifically

understands the space and the end user. Where possible, early and on-going, consultation

with the Design & Dignity Architect is recommended.

Engaging staff at all levels, family and patient representatives at application and

development stage is highly recommended.


60

Spend money on

quality durable furniture

with non-clinical feel

Furniture for all ages

(Beanbags to

armchairs)

ArchitectHigh

QualityFurnishings

Continuation of the

D&D Grants Scheme

Further roll out of the

programme to other

clinical settings

On-going leadership in

evidence based design

IHF Role D&DPAG

To ensure corporate

agenda on end-of-life

care

To manage and support

fundraising for

sustainability

Architect engaged

early

Architect who

understands the space

and has healthcare

experience

Family room on every

ward in acute care

National agenda to

support Design &

Dignity Programme

Routine cleaning

schedule

Always fully stocked

(tea, cups,

refreshments, etc.)

FullyServiced Rooms

Wifi ready

Charging station

Video conferencing

facilities (e.g. Skype)

Norm not a luxury

FutureProof

Part of New Builds

Family room or

bereavement suite part

of new builds

Mortuary situated away

from bins and supplies

areas

Looking to the Future

Recommendationsat a glance


61

3.2.3 Irish Hospice Foundation Reflection on the Design & Dignity Programme

For the Irish Hospice Foundation, whose core objective is to improve end-of-life care for all, this has

been a flagship project for the last number of years. They acknowledged that incorporating the Design

& Dignity guidelines requires a huge amount of support and resources. However, it has a direct positive

impact on patients and their families, and is very worthwhile.

“Operating on a small and local scale with limited investments, this project is making a very real difference to people at the most difficult time in their lives.”

“It requires huge support, grit and determination but it has been worth it!

Factors that have contributed to the success of this project from the IHF’s perspective include having a

multidisciplinary project team and a strong relationship between the IHF and HSE Estates. Buy-in from

management was also identified as a key factor in the success of this project, and any other project like

this.

“Changes in management can set a project back. In one hospital, their new build has family rooms but some have been hijacked by medical teams”

“Changeover of hospital management can have a negative impact”

The importance of design features such as art work, natural light, high quality furniture and soft

furnishings was recognised. These all have a significant impact on patient and family experiences and

should be taken into account when the budget is being created.

“The last 10% of the budget has the most impact”

The IHF recognise that even thought this project is well-established, hospitals still require significant

support, including behind the scenes support, as well as financial support if the vision of having end of

life sanctuaries in every adult, paediatric and maternity hospital in Ireland is to be achieved.

“I think we’ve made amazing strides however there are still many new builds outside the grants scheme which are not incorporating the D&D guidelines despite them adopted by the HSE”

The knock-on effect of Design & Dignity can also be seen across many hospitals. Following the creation

of the first Design & Dignity family room in the Mater Hospital, staff from another ward fundraised and

developed a family room replicating the Design & Dignity funded room. In addition, the hospital used

the ‘Design & Dignity Assessment Tool for Family Rooms’ to assess the remaining family rooms and

established a family room campaign. To date they have a total of 13 new family rooms and two comfort

care family suites to enhance the provision of end-of-life care.


62

In the Mid-Western region, the HSE Estates Manager involved in the development of the family room

in Nenagh Hospital seized an opportunity to create a family room within a new development in Ennis

Hospital. As this room was incorporated within a new development and replicated the Design & Dignity

model, it cost one third of the price of the Nenagh Room. It has also been reported more generally that

Estates Managers are very proud to be associated with Design & Dignity and are increasingly feeling

more ownership of the projects.

The hospital projects are also enhancing team work and staff morale. Without exception, staff have

reported on the overwhelmingly positive reactions across their sites and that they are very proud to be

able to offer well-designed dignified spaces to families at such difficult times and as one Palliative Care

Nurse wrote ‘honestly, I can’t describe the benefit of the room. You can see the stress lift from relatives

when they come into the room …. It has given us all great pride in our work and in our caring for these

families.’ The projects are also enhancing the culture of care across hospitals. In some hospitals the

development of the new facilities has been the catalyst for the launch of the Hospice Friendly Hospitals

Programme. During the opening of a new ICU waiting area, a Consultant Anaesthetist admitted that, prior

to the renovation of the waiting area, he had never considered the impact of the physical environment for

relatives of critically ill patients and, as one bereaved relative described it, “knowing that our Mum was

critical and may not make it – waiting in that waiting room outside the ICU only added to our trauma. It was

cold, it was uncomfortable…it was totally impersonal” (Ó Coimín et al. 2017, p.72).

There have also been peripheral benefits, for example the newly refurbished mortuary in Sligo is

described by staff as the ‘nicest building in the hospital’ and is used for choir practice as well as

Hospice Friendly Hospital Committee meetings. Designed by the IHF Architectural Advisor, it won The

Healthcare Building of the Year Award in April 2018. Another notable success has been the HSE’s

adoption of the Design & Dignity Guidelines, which were developed by the Project Team, for all new and

refurbishment work.

Mary Lovegrove, Manager, Design & Dignity Programme & Ronan Rose Roberts, Design & Dignity

Architecture Advisor, November 2018


63

AGENCY FOR HEALTHCARE RESEARCH AND QUALITY

2007. Transforming Hospitals: Designing for Safety

and Quality. Washington DC: AHRQ.

ALTIMIER, L. 2004. Healing environments: for patients

and providers. Newborn and Infant Nursing Reviews

4, 89-92.

BATTISTO, D. & FRANQUI, D. 2013. A Standardized Case

Study Framework and Methodology to Identify “Best

Practices”.

BECKSTRAND, R. L., RASMUSSEN, R. J., LUTHY, K. E. &

HEASTON, S. 2012. Emergency nurses’ perception

of department design as an obstacle to providing

end-of-life care. J Emerg Nurs, 38, e27-32.

BOSCH, S., BLEDSOE, T. & JENZARLI, A. 2012. Staff

Perceptions Before and After Adding Single-Family

Rooms in the NICU. Herd, 5, 64-75.

BRERETON, L., GARDINER, C., GOTT, M., INGLETON, C.,

BARNES, S. & CARROLL, C. 2012. The hospital

environment for end-of-life care of older adults and

their families: an integrative review. J Adv Nurs, 68,

981-93.

CLARKE, G. & GRAHAM, F. 2013. The Hospice Friendly

Hospitals Programme in Ireland: A Narrative

History. Dublin: Irish Hospice Foundation.

DEPARTMENT OF HEALTH AND SOCIAL CARE 2013.

More care, less pathway: a review of the Liverpool

Care Pathway. London: UK Government.

FERRI, M., ZYGUN, D., HARRISON, A. & STELFOX, H.

2015. Evidence-based design in an intensive care

unit: end-user perceptions. BMC Anesthesiol, 15,

57.

FRONCZEK-MUNTER, A. 2013. Evaluation methods for

hospital facilities. 215-226.

GARDINER, C., COBB, M., GOTT, M. & INGLETON, C.

2011. Barriers to providing palliative care for older

people in acute hospitals. Age Ageing, 40, 233-8.

GOLA, M., FRANCALANZA, P. C., GALLONI, G., PAGELLA,

B. & CAPOLONGO, S. 2016. Architectures for

paediatric palliative care: how to improve quality

of life and environmental well-being. Ann Ist Super

Sanita, 52, 48-55.

HEALTH SERVICE EXECUTIVE 2007. WORKSTREAM 3:

High Level Operational

Policies and Hospital Sizing. Dublin: HSE

HEALTH SERVICE EXECUTIVE 2016. National Standards

for Bereavement Care Following Pregnancy Loss

and Perinatal Death. Dublin: HSE.

HUGODOT, A. & NORMAND, C. 2007. Design & Dignity,

and cost-effectiveness at the end-of-life care in

hospital: a review of the litarature. Dublin: Trinity

College Centre for Health Policy and Management.

IRISH HOSPICE FOUNDATION 2007. Design & Dignity

Baseline Review. Dublin: IHF.


Guidelines for Physical Environments of Hospitals

Supporting End-of-Life Care. Dublin: IHF.

IRISH HOSPICE FOUNDATION 2010. Quality Standards

for End-of-Life Care in Hospitals: Making end-of-life

care central to hospital care. Dublin: IHF.


Style Book. Transforming End-of-Life Care in

Hospitals One Room at a Time. Dublin: IHF.

IRISH HOSPICE FOUNDATION 2015. The Hospice

Friendly Hospitals Programme Guidance document

for using the end of life symbol. Dublin: IHF.

KOTZER, A. M., ZACHARAKIS, S. K., RAYNOLDS, M.

& BUENNING, F. 2011. Evaluation of the built

environment: staff and family satisfaction pre- and

post-occupancy of the Children’s Hospital. Herd, 4,

60-78.

LOWTON, K. 2009. ‘A bed in the middle of nowhere’:

Parents’ meanings of place of death for adults

with cystic fibrosis. Social Science & Medicine, 69,

1056-1062.

MCKEOWN, K., HAASE, T., PRATSCHKE, J., TWOMEY,

S., DONOVAN, H. & ENGLING, F. 2010. Dying in

Hospital in Ireland: An Assessment of the Quality

of Care in the Last Week of Life, Report 5, Final

Synthesis Report. Dublin: IHF.

MURRARY, E., MCLOUGHLIN, K. & FOLEY, S. 2013.

Access to Specialist Palliative Care Services and

Place of Death in Ireland: What the data tells us.

Dublin: Irish Hospice Foundation.

NADERI, J. R. & SHIN, W.-H. 2008. Humane Design for

Hospital Landscapes: A Case Study in Landscape

Architecture of a Healing Garden for Nurses. HERD:

Health Environments Research & Design Journal, 2,

82-119.

NATIONAL HEALTH SERVICE ENGLAND 2010. The route

to success in end-of-life care – achieving quality in

acute hospitals. London: NHS.

NATIONAL HEALTH SERVICE ENGLAND 2015.

Transforming end-of-life care in acute hospitals. The

route to success ‘how to’ guide. London: NHS.

Ó COIMÍN D., KORN B., PRIZEMAN G., DONNELLY S.,

HYNES G., CURRAN M., CODD M. 2017 Survey of

Bereaved Relatives: VOICES MaJam. Dublin: Mater

Misericordiae University Hospital and St. James’s

Hospital.

Bibliography


64

O’SHEA, E., MURPHY, K., LARKIN, P., PAYNE, S.,

FROGGATT, K., CASEY, D., A., N. L. I. & M., K. 2008.

End-of-Life Care for Older People in Acute and

Long-Stay Care Settings in Ireland. Dublin: Hospice

Friendly Hospitals Programme and National Council

on Ageing and Older People.

PARKER, S. 2017. How Irish Hospitals are Transforming

Spaces for Patients and Families at the End of Life.

Dublin: IHF.

PASHA, S. 2013. Barriers to Garden Visitation in

Children’s Hospitals. Herd, 6, 76-96.

QUALITY ASSESSMENT AND IMPROVEMENT 2014a.

Effective Care and Support. Supporting services

to deliver quality healthcare: Workbook 2. Dublin:

HSE.

QUALITY ASSESSMENT AND IMPROVEMENT 2014b.

Person Centred Care and Support. Supporting

services to deliver quality healthcare: Workbook 1.

Dublin: HSE.

RASHID, M. 2014a. Space Allocation in the Award-

Winning Adult ICUs of the Last Two Decades (1993-

2012): An Exploratory Study. Herd, 7, 29-56.

RASHID, M. 2014b. Two decades (1993-2012) of adult

intensive care unit design: a comparative study of

the physical design features of the best practice

examples. Crit Care Nurs Q, 37, 3-32.

RIGBY, J., PAYNE, S. & FROGGATT, K. 2010. Review:

what evidence is there about the specific

environmental needs of older people who are near

the end of life and are cared for in hospices or

similar institutions? A literature review. Palliat Med,

24, 268-85.

ROWLANDS, J. & NOBLE, S. 2008. How does the

environment impact on the quality of life of

advanced cancer patients? A qualitative study with

implications for ward design. Palliat Med, 22, 768-

74.

SAGHA ZADEH, R., ESHELMAN, P., SETLA, J., KENNEDY,

L., HON, E. & BASARA, A. 2018. Environmental

Design for End-of-Life Care: An Integrative Review

on Improving the Quality of Life and Managing

Symptoms for Patients in Institutional Settings.

Journal of Pain and Symptom Management, 55,

1018-1034.

SLATYER, S., PIENAAR, C., WILLIAMS, A. M., PROCTOR,

K. & HEWITT, L. 2015. Finding privacy from a public

death: a qualitative exploration of how a dedicated

space for end-of-life care in an acute hospital

impacts on dying patients and their families. J Clin

Nurs, 24, 2164-74.

STAJDUHAR, K. I., FUNK, L., COHEN, S. R., WILLIAMS,

A., BIDGOOD, D., ALLAN, D., NORGROVE, L. &

HEYLAND, D. 2011. Bereaved family members’

assessments of the quality of end-of-life care: what

is important? J Palliat Care, 27, 261-9.

THE KING’S FUND 2008. Improving Environments for

Care at End of Life: Lessons from eight UK pilot

sites. London: The King’s Fund.

THE KING’S FUND 2011. Improving the patient

experience. Environments for care at end of

life. The King’s Fund’s Enhancing the Healing

Environment Programme 2008-2010. London: The

King’s Fund.

TIMMERMANN, C., UHRENFELDT, L., HOYBYE, M. T. &

BIRKELUND, R. 2015. A palliative environment:

Caring for seriously ill hospitalized patients. Palliat

Support Care, 13, 201-9.

TOFLE, R. B. 2009. Creating a Place for Dying:

Gerontopia. Journal of Housing For the Elderly, 23,

66-91.

TROCHELMAN, K., ALBERT, N., SPENCE, J., MURRAY, T. &

SLIFCAK, E. 2012. Patients and their families weigh

in on evidence-based hospital design. Crit Care

Nurse, 32, e1-e10.

VAN DE GLIND, I., DE ROODE, S. & GOOSSENSEN, A.

2007. Do patients in hospitals benefit from single

rooms? A literature review. Health Policy, 84, 153-

161.

VESELY, C., NEWMAN, V., WINTERS, Y. & FLORI, H. 2017.

Bringing Home to the Hospital: Development of the

Reflection Room and Provider Perspectives. J Palliat

Med, 20, 120-126.

WALSH, K. 2013. The Hospice Friendly Hospitals

Programme: Overview 2007 - 2013. Dublin: IHF.

WILLARD, C. & LUKER, K. 2006. Challenges to end-of-

life care in the acute hospital setting. Palliat Med,

20, 611-5.


65

Appendices

Appendix 1 Summary of Empirical & Grey Literature

Summary of Empirical Evidence

Key findings from some of the research found

specific evidence-based design features that

yielded positive results. Single patient rooms were

found to generate greater positive outcomes for

families and staff in healthcare facilities (Bosch

et al., 2012, Kotzer et al., 2011, Rashid, 2014a,

Rashid, 2014b, Rigby et al., 2010, Trochelman

et al., 2012). Design features such extra space

and furnishings such as a futon in patient rooms

accommodated families and allowed for improved

privacy, connection and dignity for families and

patients (Trochelman et al., 2012, Vesely et

al., 2017). Other positive outcomes that single

rooms accommodated were greater peace (less

noise disturbance) and control over the room

environment (temperature/lighting) (Ferri et al.,

2015, Kotzer et al., 2011, Slatyer et al., 2015,

Trochelman et al., 2012). Although important

for privacy, shared rooms can enhance social

interactions and provide companionship (Gardiner

et al., 2011, Rowlands and Noble, 2008, Sagha

Zadeh et al., 2018). Patients in an oncology unit

found that although some participants believed

single rooms increased privacy, others felt

single rooms created feelings of hopelessness

(Rowlands and Noble, 2008). Additionally, another

factor to consider in providing privacy is to ensure

the level of concealment does not interfere with

visibility between patient and staff (Sagha Zadeh

et al., 2018). Private rooms also allowed for

personalisation of the space with pictures etc.

creating a homely and domestic atmosphere as

opposed to a clinical atmosphere (Gardiner et

al., 2011, Rigby et al., 2010, Sagha Zadeh et al.,

2018, Vesely et al., 2017).

Personalising patient space in a healthcare

setting can improve comfort and satisfaction for

patients/families (Sagha Zadeh et al., 2018,

Tofle, 2009, Vesely et al., 2017) whilst increasing

staff’s ability to connect with patient by viewing

them as an individual (Rigby et al., 2010).

Attaching personal meaning to the physical space

and having the ability to control it empowered

patients (Tofle, 2009). Although homeliness

is an important feature it is difficult to obtain

with clinical regulations for infection control and

patient safety (Gardiner et al., 2011, Rigby et al.,

2010). Ensuring ambient environment measures

were adjustable (temperature, lighting, noise)

increased patient satisfaction and boosted

positive moods in patients (Sagha Zadeh et al.,

2018). Other factors that were found to improve

patient satisfaction in healthcare environments

were small wards that were bright, airy and clean

and had an environment of friendliness (Rowlands

and Noble, 2008). Smaller spaces were reported

to give a feeling of comfort in hospices as

opposed to larger spaces (Rigby et al., 2010).

Lastly, experiencing the environment through a

variety of senses comforted patients (Rowlands

and Noble, 2008).

Use of evidence-based design (EBD) in healthcare

settings also improved outcomes for staff. Staff

perceptions on the renovations of a neonatal

intensive care unit (NICU) found improved work

satisfaction and greater quality of services for

NICU patients (Bosch et al., 2012). Other reports

of staff satisfaction with EBD builds included

greater amenities for staff (storage/workspace),

layout designs, aesthetics and natural light

(Kotzer et al., 2011, Rashid, 2014a, Rashid,

2014b). Spaces need flexible configurations in

order to maximise the safety of the build (Ferri et

al., 2015, Trochelman et al., 2012) and reduce

walking time between nurses and patients in

(ICUs) (Rashid, 2014a, Vesely et al., 2017).

Larger spaces associated with EBD allowed for

greater family presence and perceptions of greater

quality of care (Ferri et al., 2015, Vesely et al.,

2017). Similarly, staff attitude such as humour,

kindness and competency appeared to create an

environment of wellbeing more than the physical


66

environment (Lowton, 2009, Rowlands and Noble,

2008). Therefore, end-of-life care environments

need to be designed to facilitate multiple forms

of social interaction among different groups

such as patients, families, and staff and to allow

connections to the outside world i.e. papers/

radios (Sagha Zadeh et al., 2018). Family facilities

need to be improved such as viewing rooms and

renovations to mortuary facilities, which in turn

may reduce stress for staff also (Gardiner et al.,

2011). Despite staff reporting that they would

recommend the use of an end-of-life care space

(Vesely et al., 2017). It was noted that some staff

felt they had little input into the design concept of

a space (Beckstrand et al., 2012).

Accessibility was another key finding that was

increased with EBD. Amenities such as Wi-Fi

(Ferri et al., 2015), parking and accessibility to

the hospital via public transport increased user

satisfaction in healthcare facilities (Rashid,

2014a, Rigby et al., 2010). Ease of access

to outdoor areas was also highlighted in the

research (Naderi and Shin, 2008, Pasha, 2013).

Nature is beneficial to well-being and therefore

can improve health in patients, family and staff

(Pasha, 2013). Outdoor areas for staff are

necessary for creating a private and quiet space

for staff to relax and thus improve the quality of

implemented healthcare. Nature is consistently

mentioned as a positive feature in healthcare

environments (Gardiner et al., 2011, Rowlands

and Noble, 2008, Sagha Zadeh et al., 2018, Tofle,

2009). Direct views of nature, bright and natural

light and access to outdoor areas were seen as

pivotal. If direct views of nature were not possible,

creation of nature through ambient lighting or art/

plants were mentioned (Rowlands and Noble,

2008, Sagha Zadeh et al., 2018). Previous EBD

designs can be reused and govern the way for

future EBD builds (Rashid, 2014a). In all it seems

the key findings suggest that use of EBD can allow

for better outcomes for staff and for patients.


67

Literature Reviewat a glance

Supports socialinteraction

Privacy

Personalisationand homely

environments

Contact withnature

Single &Mixed rooms

User friendly & efficient space

allocation

Low noise levels & soundproofing

Key components associated with improved outomes


68

Summary of Grey Literature

Grey literature was sourced to review unpublished

empirical studies, policy or guidance documents,

annual reports and service plans in relation to

evidence based design in end-of-life or palliative

care. The countries which were included in this

scoping review were based on the volume of

empirical research outputs. Grey literature was

examined from key palliative and government

healthcare websites in Ireland, the United

Kingdom (UK) and United States of America (USA).

Findings from the grey literature will be presented

through a narrative synthesis of each country, with

a focus on key design features and components

associated with improved outcomes. Resource

implications and enablers and barriers to the

development and sustainability of EBD will also be

examined where applicable.

Ireland

In the Irish context the majority of literature

relating to evidence base design in end-of-life

care has been published by the Irish Hospice

Foundation (IHF). In 2007, a baseline review

published by the IHF and Tribal Group UK

developed a physical environment assessment

framework with the hospitals participating in

the Design & Dignity programme. This report

highlighted that despite there being clear

guidance on the standardisation of certain

hospital settings, there was a dearth of guidance

regarding the build of a physical environment for

those receiving end-of-life care (Irish Hospice

Foundation, 2007). Recommendation from the

assessment framework that created a baseline

standard for future sites to improve the physical

build in end-of-life care included accessibility for

patients, staff and their families, privacy and

confidentiality, having environmental control, as

well as ensuring cultural adaptability, orientation,

and wayfinding. Ambience, functionality, service

adjacencies, communication, specific mortuary

facilities, and external spaces were also

discussed in detail and highlighted as key areas

to improve patient and relative’s experiences (Irish

Hospice Foundation, 2007). Similar findings were

echoed in the End-of-life care for Older People in

an Acute and Long Stay Care Setting in Ireland

report (O’Shea et al., 2008), which identified that

the physical environment in end-of-life care was

identified as a place where people both live and

die, and the availability and use of single room

and family facilities was recommended.

Following from this the IHF published Design

& Dignity guidelines in 2008 which provided

necessary guidance for the design and planning

of end-of-life facilities within acute hospitals

(Irish Hospice Foundation, 2008). This guidance

document provided rationale for supporting

the guidelines and identified the key principles

underpinning their development; dignity, privacy,

sanctuary, choice and control, safety and universal

access. The Hospice Friendly Hospitals (HfH)

programme guidelines encouraged development

in the areas of arrival; waiting and wayfinding;

internal wards and departments including patient

accommodation and workstations; multi-functional

communal spaces providing art and music, multi

faith areas, gardens and facilities for relatives

and staff. Guidance on ensuring a respectful and

reassuring atmosphere within a mortuary and

bereavement suite was also provided.

Since the development of these guidelines the

IHF in collaboration with the HSE launched the

Design & Dignity Style Book: Transforming End-of-

Life Care in Hospitals One Room at a Time (Irish

Hospice Foundation, 2014). The purpose of this

style book was to support the development of

end of life spaces for all professionals involved in

project builds, including patient representatives,

hospital staff, and architects. In terms of

practicalities a number of recommendation were

made, including the benefits in use of acoustic

floor finishes, PVC foil wrapped cabinet doors,

and careful consideration in the selection of

artwork. Family rooms within an acute setting

should provide a three-pronged approach to

development. Firstly, a dedicated private space

should be available to patients and their families.

Secondly, overnight accommodation or a place

of rest should be available to family members

when visiting their relative. Finally, each area

should have a kitchenette with appropriate

facilities and appliances. Location, way signage,

aesthetic, physical and sensory environment

of each dedicated space also needs careful

consideration. It was recommended that

each Emergency Department should have a


69

bereavement suite, comprising of a family room

and ajoining and viewing room. In a time that is

often traumatic for families, the bereavement

suite should generate a respectful and peaceful

clinical environment. External noise, location, soft

acoustics, temperature, ventilation furnishings,

and the signage and naming of the suite should

all be considered in the build of this environment.

Mortuaries, viewing rooms, and garden settings

were also highlighted as key areas which require

a guided refurbishment in both their concept and

creation. It is worth noting that a multi-faith room

is required to meet the needs of families from

multi-cultural backgrounds.

Prior to the development of the style book the IHF,

supported by The Atlantic Philanthropies, and the

HSE published a “Quality Standards for End-of-Life

Care in Hospitals: Making end-of-life care central

to hospital care” (Irish Hospice Foundation, 2010)

This report identified four main quality standards

that hospital groups should adhere to, to ensure

positive outcomes for patients and their families

receiving end of life. These standards are based

on four key principles. Firstly, the mission of each

hospital is to ensure that systems are in place to

meet the needs of patients. Secondly, that staff

are supported in their roles within the system

through training and development opportunities.

Thirdly, that patients’ needs are met and finally

that each family is supported, informed and kept

informed. To continue to improve outcomes the

use of single rooms, areas for privacy, prayer,

personal hygiene and refreshments should be

made available to patients and their families (Irish

Hospice Foundation, 2010).

To ensure that these standards are met and that

end-of-life care supports dignity and privacy the

use of the ‘Design & Dignity Guidelines for Physical

Environments of Hospitals Supporting End-of-Life

Care’ is encouraged (Irish Hospice Foundation,

2008). Walsh (2013) published an overview of

the HfH hospital programme from 2007-2013,

concurring with a planned approach to improving

end-of-life care settings with the use of the Design

& Dignity guidelines. The physical environment

was reviewed under the HfH programme’s audit

and standard activities, emphasising that the

development of these guidelines informed

quality standards and generated awareness of

the significance of the physical environment

for patients and their families end-of-life care.

Resource implications regarding the maintenance,

development and administration of this

programme and exemplar sites was recognised,

with ongoing support and commitment required

from the HSE estates and grant schemes.

The “Hospice Friendly Hospitals Programme

Guidance document for using the end of life

symbol” guides use of the end of life symbol

throughout hospitals (Irish Hospice Foundation,

2015). The symbol - a three stranded white spiral

on a purple background symbolises the cycle

of birth, life and death. The roots of the symbol

stem from Irish history and are not associated

with any spiritual denomination. Displaying the

symbol after someone dies can be helpful in

reminding staff to facilitate a quiet and respectful

atmosphere. Where to display the symbol must

be consistent throughout the hospital with the

document suggesting a display at the entrance

of where an individual has died; at nurse’s

workstations; at the door of the room where an

individual has died (after discussion with their

family) and in bereavement suites and mortuaries.

Public use of the symbol in the main entrance,

information stands, waiting areas throughout the

hospital informs individuals of the hospital link to

the HfH programme.

The Hospice Friendly Hospitals Programme

commissioned an audit titled “A National Audit of

End-of-Life Care in Hospitals in Ireland, 2008/9”

evaluating the quality of health care in hospitals

in Ireland – specifically in the last week of life

(McKeown et al., 2010). The audit lists four

standards relating to staff, patients, families and

hospitals as a whole. Not only providing standards

in hospitals, the audit hopes the standards will

be incorporated to support end-of-life within

hospices, long term settings and in the home.

Standard 1.3 refers to the physical environment

and three aspects were found to be of statistical

significance to care at the end of life. The three

aspects were where the patient died (either in

single patient room or multi-bedded ward); the

condition of the room/ward where the patient

spent the last week of their life; the standard

of the mortuary in which they were reposed.

The audit explains that despite advantages to


70

single patient rooms they represent on average

only 15% of beds in acute hospitals. Symptom

management and symptom experience are better

in single patient rooms. The audit reports that

coping with a patient’s death is improved in a

single room according to families. Analysis of the

report showed the condition of the room or ward

where the patient died made an impact on the

quality of care. The environment where patients

spent their final days was assessed by nurses

who rated the environment based on privacy,

dignity, the environment (nature, light, noise), and

control (having ability to alter the surrounding

environment). The dignity of a room had statistical

significance on the quality of care. Dignity

was found to improve symptom management,

patient care, and coping with a patient’s death.

Healthcare could be improved with increased use

of single patient rooms and improving physical

environment of wards containing multi-beds.

Overall, the audit confirms the positive impact

of single patient rooms on care outcomes for

individuals at end of life. They are illustrated to

improve staff communication with relatives as

well facilitating relatives to stay overnight and be

“present at the moment of death” (McKeown et

al., 2010).

“How Irish Hospitals are Transforming Spaces

for Patients and Families at the End of Life” is a

case study report on behalf of the Irish Hospice

Foundation (Parker, 2017). The case study

focused on four hospitals from city and rural

settings to illustrate their experiences, challenges

and success. Several points of recommendation

were summarised based on their key learning

experiences. Some of the case studies found they

were met with staff resistance when implementing

the project due to its requirement for staff to alter

the way they work. Allocating a “key champion” or

team lead/manager to boost staff morale, support

upkeep of the project and make key decisions is

essential. Securing an architect who understands

the purpose of the project is recommended;

reviewing architect drawings can ensure their

understanding of the project. Allocation of

sufficient funding to high quality furniture and

art pieces is recommended. Specifically, the

report suggests 1% of the overall budget should

be spent on art pieces alone. Involvement of

staff members from the onset of the project can

help inform decision-making: as staff give an

insider perspective and understanding of how

the environment must work for patients and staff

alike. Involving infection control teams from the

onset of the project is additionally encouraged.

Another key learning point is to expect delays

as often teams found the project more time

consuming than originally anticipated. Pacing the

project ensures high quality is maintained which

is particularly important for the finishing art work

and furnishings. The case studies reported that

if projects were rushed towards the end this

resulted in low-quality furniture which undid the

quality of work. Lastly, the case studies highlight

the importance of ensuring the room is being

used for its intended purpose.

As well as report and guidance documents, one

unpublished literature review explored Design &

Dignity and the cost effectiveness at end-of-life

care in hospital (Hugodot and Normand, 2007).

Details regarding hospital structures such as the

benefits of single versus shared rooms and the

importance of internal environments with a focus

on control, mobility, homeliness and access to

outside environments are not dissimilar to the

empirical findings of this current review. Hugodot

and Normand (2007) concluded that functional

environments improve patient outcomes, staff

satisfaction, cost effectiveness and support

patients dealing with illness.

The Health Service Executive (HSE) published four

documents relating to guidelines for supporting

services to give quality healthcare. Two workbooks

were published as part of Quality Assessment

and Improvement to implement standards by a

process of continuous improvement. Workbook 1

titled “Person Centred Care and Support” includes

guidelines to support staff to achieve high

quality care. Regarding the physical environment,

standard 1.6 outlines the importance of reviewing

healthcare facilities and environments to ensure

their efficiency in providing privacy and dignity

through appropriate “design and management”

(pg.18). This standard is categorised at a

level of continuous improvement suggesting

more improvements could be made (Quality

Assessment and Improvement, 2014b). Workbook

2 titled “Effective Care and Quality Support”

describes the physical environment as a mediator


71

in delivering effective care. Standard 2.7

describes that within palliative health care the

physical environment must support the effective

management of services as well as protecting the

patient’s privacy and dignity (Quality Assessment

and Improvement, 2014a).

The HSE National Standards for Bereavement

Care following Pregnancy Loss and Perinatal

Death highlights design adaptations for a

maternity setting. Drawing upon the IHF Design

& Dignity guidelines, the report outlines features

such overnight rooms and refreshment facilities.

Spaces dedicated to bereavement care need to be

designed with comfort, quietness and privacy in

mind. The report highlights the need for funding to

support Bereavement Care specific to a maternity

setting (Health Service Executive, 2016).

A report outlining plans for the Mater Hospital

National Paediatric Centre Tertiary Centre (NPH)

outlines the centre’s aims to organise efficient

delivery of services within the hospital. With a

focus on family support, the Family Resource

Centre is described as an important feature of

the NPH Tertiary Centre (Health Service Executive,

2007). The Resource Centre aims to provide a

retreat and resource for families for patients.

Other ambitions for the Centre are to include

facilities such as showers, personal care facilities

for disabled children/adolescents, baby feeding,

nappy changing, storage for buggies/prams,

lounge and dining areas as well as reflection/

prayer rooms. The design framework for the

hospital is to feature external areas for peaceful

reflection as well as areas to accommodate larger

gatherings. Moreover, wards should facilitate

flexible bed allocation. The benefits of single

patient rooms are debated within the report, with

advantages such as increased privacy, infection

control, operational flexibility (designated wards)

and disadvantages such as feelings of isolation

for the children and observation obstructions for

nursing staff. Key recommendations for designing

paediatric patient rooms include the following;

space for the child’s needs (sleep, play and

education); space for clinical staff as well as hand

wash facilities and monitoring; space for parents

to sleep overnight; space for parents to store

personal items without impeding clinical staff

and space for attached en suite facilities. Natural

light as well as views from the patient bed are

suggested by the report.

United Kingdom

The majority of grey literature from the United

Kingdom has been published by the King’s Fund

and the National Health Service (NHS). Similar to

the Design & Dignity Programme, the Enhancing

the Healing Environment “is a programme that

works to encourage and enable local teams,

led by clinical staff, to work in partnership with

service users in order to improve the environment

in which they deliver care” (The King’s Fund,

2011, pg. 9). Since its launch in 2000 by the

King’s Fund charity, the programme has provided

support to over 202 teams from 143 NHS trusts

in settings such as hospices, hospitals and

prisons. The programme comprises of two main

functions – the first is a development programme

to support multidisciplinary teams as well as

training and education support. The second

function is to provide project grants to aid teams

in physically enhancing the patient environment.

The programme also encourages users of the

environment – those receiving and giving care – to

be a direct part of creating and implementing the

design project.

An evaluation was carried out by the Sue Ryder

Care Centre at the University of Nottingham which

was jointly funded by the Department of Health

and The Kings Fund (The King’s Fund, 2011). The

evaluation comprised of 25 projects throughout

the UK ranging from bereavement suites,

mortuaries, gardens and palliative care facilities.

Findings from the main evaluation took particular

focus on mortuaries and bereavement facilities

to provide standards and recommendations

for the NHS health building guidance. Six

recommendations were outlined to apply to

the refurbishment of bereavement facilities.

Architecturally the build is recommended to

have a “stylish contemporary feel” with cultural/

religious neutrality and to achieve an atmosphere

of “calm contemplation” to reassure (p.86). In

terms of location, the facility should be in a quiet

area away from the busy hospital areas. Signage

and accessibility are important – in particular

car parking and private reception areas. Nature

should be inserted into bereavement spaces in


72

the form of outdoor areas at the entrance or exit

of the facility as a “relaxing transitional space”

(p.86). Body viewing suites should allow space

for either side body viewing and where possible

a one-track circulation route out to a garden or

courtyard. This will minimise interruptions for

families making their way into the entry in dual

use facilities. These facilities must also ensure

any clinical areas are separate from viewing

areas such as clinical corridors where staff may

access the facility or bodies may be moved.

High quality furniture is recommended as well

as light and neutrality. Throughout this space

should feature accent pieces such as individual

art work, stained glass or decorative textiles.

Viewing facilities should make use of top-lighting

to provide focus in the room and create a serene

and contemplative atmosphere. Environmental

conditions must be considered and noise must be

excluded within the body viewing area. Negative

air pressure, with ventilation in the body viewing

area is recommended to ensure odours to not

escape from the clinical areas. High quality air

seals around access doors to clinical areas are

recommended.

The key findings of the evaluation included the

following; feedback from visitors and service

users in terms of support; challenges; project

completion and funding. A common remark

was the peacefulness users experienced in the

space was often in contrast to the clinical and

busy nature of the wider hospital. Every team

felt supported by their sponsors and defined

this support as proactive or reactive. Many

teams described challenges they faced. The

most common was securing resources, followed

by limited time, issues with location, issues

with building and finally attitudes within teams.

Challenges in terms of project completion varied

from securing additional funding, securing

admission to spaces, unforeseen structural

issues, revising designs and weather disruptions

(garden projects). Finally, the estimate of funding

for the initial projects increased from £45,000 to

£117,000, with a total estimated cost across the

projects of £2.6 million.

A report titled “Improving environments for care

at end of life” (The King’s Fund, 2008) refers

to a pilot study for the Environment for Care at

End of Life (ECEL). The pilot was an adaptation

of the King’s Fund’s Enhancing the Healing

Environment (EHE) programme which is still

currently ongoing with the most recent evaluation

report in 2011 (See above). This pilot study

focused on the environment of care for those

at end of life and consists of eight projects in

hospices and hospitals throughout England and

Scotland. Mortuary and viewing facilities made

up half of the projects whereas the other four

consisted of redesigning a bereavement suite,

transforming a visitor’s room, palliative care

rooms and renovating hospice patient rooms.

Key recommendations emerging from the study

suggest all end-of-life facilities should include

the following; a designated room for private

discussions between patients and families;

optional single-patient rooms designed to evoke

a sense of homeliness as well as room features

which can be controlled by the patient; sleep over

facilities for families/friends which have catering

and internet facilities; spaces where families and

patients can gather and meet with staff in an

informal way and appropriate viewing spaces for

families to spend time with their loved ones once

they have passed away.

Due to emerging findings from the pilot study and

the literature research of the ECEL Programme,

the King’s Fund recommends further academic

research into the following; how features within

the physical environment impacts on individuals

receiving end-of-life care; language and signage

use symbolic of end-of-life care facilities;

initiatives to involve terminally ill individuals in

the design and delivery of palliative services and

designating end-of-life care facilities within acute

wards. Moreover, based on discussions with site

teams a pattern has emerged in the last decade

regarding individuals use of mortuary facilities.

Although undocumented, participants group

sizes visiting mortuaries has increased (up to

20). Mortuary facilities will need to adjust to this

change in terms of the location, environmental

design and maintenance of the facility. It is

important to realise that, for many families visiting

the bereavement facilities, this might be their last

and only interaction with the ECEL programme

and thus it is important for the health care

environment to make a lasting impression.


73

A “how-to” guide published by the NHS aims to

support healthcare staff in transforming end-

of-life care in acute settings (National Health

Service England, 2015). The guide draws on “The

route to success in end-of-life care – achieving

quality in acute hospitals” (National Health

Service England, 2010) which highlighted best

practice models developed by acute hospital

trusts and supported by The National End-of-life

care Programme (now part of NHS Improving

Quality). It provides a comprehensive framework

to enable acute hospitals to deliver high-quality

person-centred care at the end of life. The guide

outlines the need for the healthcare environment

to support discussions with patients as the end

of life approaches. It reports that acute settings

need to incorporate spaces that facilitate private

discussions between staff and patients in a safe

and secure way. Providing privacy can facilitate

individuals and their families to initiate open and

honest discussions and form the basis of advance

care plans. Ward environments must provide

dignity and respect for individuals and their

families. Lastly, the report states the importance

of encouraging feedback by use of comments

and complaints to maintain a respectful ward

environment.

The Environmental Design Audit Tool (2007)

funded by the Kings Fund and the Prince’s

Foundation in the UK was designed based on

the results of a Hospice Design competition. The

ten principles described were extracted from the

competition and help inform design principles in

health care environments which can be applied

to older individuals and those at end of life. The

ten principles are as follows. Nature should be

“carefully threaded” into all aspects of the design

builds from outside areas to inside plants as

the “landscape has a deeply profound effect on

people” (The Kings Find & Prince’s Foundation,

2007, pg.3). The area should use nontoxic

building materials that are grown from the ground.

These materials age beautifully with time. The

Elements: refers to ventilation and natural light

access which should be incorporated where

possible and controllable (opening windows).

The report also recommends the use of moving

water and the observation of lit flames through

a medium such as glass. The facility should be

organised that makes it clear whether an area

is public or private via “natural thresholds and

devices that allow people to navigate easily

around the building” (The Kings Find & Prince’s

Foundation, 2007, pg.3). The design of the

build should portray dignity for its users via

organisation of private versus public areas of the

building. Comfort should be enhanced by allowing

people to interact with the design and by use of

homely décor that are domestic as opposed to

clinical. The building should be made of materials

that are robust as well as using a design that is

economic. Art or craft pieces should be chosen

throughout the hospital that give a message of

love, compassion and caring. All areas of the

hospital should respect the way people perceive

time; some may want to pass time if in pain

whereas other might want to slow time to enjoy

their last moments. The build must be beautiful in

its relationship with nature, through the use of fine

proportions, simple harmonic relationships and

proportioning systems (The Kings Find & Prince’s

Foundation, 2007).

The final report from the United Kingdom is a

review of the Liverpool Care Pathways (LCP)

- developed by the Royal Liverpool University

Hospital and the Marie Curie Hospice in Liverpool

for the care of terminally ill cancer patients

(Department of Health and Social Care, 2013). In

reviewing experiences of the LCP, the environment

in which individuals die was a concerning theme

and some recommendations are outlined. Private

rooms should be a priority for those who are

dying. Understandably this is not always possible.

In these circumstances, if the wishes of the

patient are known, best efforts should be made

to fulfil these such as playing music, decorating

with flowers, pictures or other wishes which can

accommodate both their comfort and emotional

well-being. Additionally, extra chairs should be

made available beside the patient bed and clear

signposting to areas where families can spend

time privately/get refreshments. Carers and family

members should be granted request for private

rooms for their loved ones, featuring windows to

the outside world/views which can open to allow

fresh air, if air-conditioning is not satisfactory.


74

USA

The Agency for Healthcare Research and Quality

(AHRQ) defines evidence-based design (EBD) as

“a term used to describe how the physical design

of health care environments affects patients

and staff” (Agency for Healthcare Research

and Quality, 2007, p.2). Single-patient rooms,

enhanced design layout for patients and staff,

greater accessibility to staff workstations and

use of noise-reducing construction materials were

defined as key examples of EBD in healthcare

settings. The report describes design features

which increase patient satisfaction. Enablers

for patient satisfaction are single-patient rooms

featuring noise-absorbing ceilings and limited

invasive noises (intercoms) as they improve the

healing environment. Additionally, reduced noise

can improve patients sleep quality thus increasing

overall wellbeing and reducing depression.

Improved way-finding in hospitals reduces

stress, anxiety and feelings of helplessness

among patients. Design features that increase

way-finding include improved corridor layouts

and signage. Additionally, design features such

as natural light, art works and views of nature

improve the healing environment for patients. The

AHRQ reported evidence which found increased

patient satisfaction when provided with adequate

space for family interaction within patient rooms.

Additional to patient satisfaction, EBD has been

shown to reduce staff burnout rates by limiting

physical demands on staff. Design features

such acuity-adaptable rooms, decentralising

nursing stations and designing patient beds to

reduce burden on staff improve workflow and

relieve physical demands on staff. Evidence in

support of single-patient rooms (improved patient

quality outcomes) led the American Institute of

Architecture in 2006 to recommend single-patient

rooms in construction guidelines for healthcare

design standards.


75

Accessibility for patients,

staff and their families

Incorporate privacy and

confidentialty

Ensuring cultural

adaptability, orientation, and

wayfinding

Integrate environmental

choice, control and safety

Provide an aesthetic,

physical and sensory

environment

Use of the end-of-life

symbol throughout hospitals

Personal hygiene and

refreshments should be

made available to patients

families

Ensure quality standards

using Design & Dignity

Guidelines and Style Book

Incorporate specifc

recommendation for key

areas such as mortuaries,

emergency departments,

bereavement suites,

paediatric areas, viewing

rooms and garden settings

Allocate project champions,

sufficent funding and

ensure staff involvement

IRELAND

Encourage end users to be

involved in the development

of the design

Include stylish,

contemporary and homely

interior, with cultural

neutrality and spects of

nature

Provide signage and ensure

the area is accessible

Private and dignified rooms

should be away from the

busy hospital environment

Minimise family

interruptions through

viewing suites

High quality furniture is

recommended as well as

light and neutrality

Incorporate art work,

stained glass or decorative

textiles

Environmental conditions

must be considered- such

as noise, air pressure and

ventilation

Include designated rooms

for private discussions

between patients and

families

Ensure high standards are

maintained through the

use of “how to” guidelines

published by the NHS

Provide single-patient rooms

where possible

Ensure an enhanced design

layout for patients and

families

Reduce noise to enhance

healing environment

Increase way finding through

improved corridor layouts

and signage

Incorporate design features

such as natural light, art

works and views of nature

Decentralise nursing

stations and improve

workflow incorporating

acuity-adaptable rooms

United Kingdom USA

Overview of grey literature recommendations


76

Appendix 2a Emergency Department Bereavement Suite Assessment Tool

5

This tool is designed to assist hospitals to assess the standard of bereavement suites in line with the Design & Dignity Guidelines. These Guidelines have been adopted by the HSE for all new building and refurbishment projects.

Name of Hospital

Design & Dignity CriteriaWeighted

scoreAssessment

scoreComments

There is a bereavement suite available.

The bereavement suite is located within the emergency department.

1

3

The bereavement suite avoids crossing clinical or highly trafficked areas.

1

Visitors to the bereavement suite do not have to return through the reception area.

1

Suitable vacant/engaged signage is used at the door to the room.

1

The bereavement suite maintains privacy.

1

The bereavement suite is accessible for people with physical & cognitive impairment

1

The bereavement suite comprises of a viewing area where the deceased person’s body is laid out and adjoining family room.

3

The bereavement suite and adjoining family room are separated by a folding partition.

2

The bereavement suite provides adequate space for a family group to gather.

1

The bereavement suite excludes external noise as far as possible.

1

The temperature in the bereavement suite can be maintained at room temperature.

1

The bereavement suite has access to natural light.

1

Natural ventilation can be accessed via opening windows.

1

The bereavement suite can facilitate individual cultural, spiritual and religious wishes

1


77

Summary of assessment

Overall Score (out of 30)

Paediatric score (out of 32)


The bereavement suite aesthetic finish

makes it a respectful, protective and a The bereavement suite asthetic finish

non-clinical environment.

2

The bereavement suite contains high quality furniture in good condition.

2

2

The bereavement suite contains suitable art-work which enhances the environment.

2

High quality lighting fixtures are controllable particularly for the area over the deceased person’s body

1

The bereavement suite and has access to a toilet.

1

Refreshment facilities including tea, coffee and water can be provided for in the adjoining family room

1

Bereavement suite supporting for paediatric deaths have a range of bed sizes/cots available.

1 (n/a)

Extra paediatric beds / cots can be stored and locked out of sight of families and visitors

1 (n/a)


scoreAssessment

scoreComments


78

Appendix 2b Mortuary Assessment Tool

Design & Dignity Criteria Weight Score

Assessment Score

Comments

There is a mortuary available 3

The mortuary is located within the hospital 1

The mortuary avoids crossing clinical or highly trafficked areas

1

Visitors to the mortuary do not have to return through the reception areas

1

Suitable vacant/engaged signage is used at the door to the room

1

The mortuary maintains privacy 1

The mortuary is accessible for people with physical and cognitive impariment

1

The mortuary comprises of a viewing area where the deceased persons body is laid out with an ajoining family room

3

The mortuary facility provides adequate parking 1

The mortuary provides adequate space for a family group to gather

1

The mortuary provides adequate space for two families groups to use the facility simultaineously

1

The mortuary excludes external noise as far as possible

1

Mortuary Asssesment Tool

This tool is designed to assist hospital to assess the standard of mortuaries in line with the Design & Dignity Guidelines. These Guidelines have been adoped by the HSE for all new building and refurbishment projects.

Name of Hospital


79

Design & Dignity Criteria Weight Score

Assessment Score

Comments

The temperature in the mortuary can be maintained at room temperature

1

The morturary has access to natural light 1

Natural ventilation can be accessed via opening windows

1

The mortuary can facilitate individual cultural. spiritual and religious wishes

1

The mortuary aesthetic finish makes it a respectful, protective and a non-clinical environment

2

The mortuary contains high quality furniture in good condition

2

The mortuary contains suitable art work which enhances the environment

2

High quality lighting fixtures are controllable particularly for the area over the deceased persons body

1

The mortuary has access to a toilet 1



Paediatric score



80

Appendix 2c Family Room Assessment Tool

This tool is designed to assist hospitals to assess the standard of family rooms in line with the Design & Dignity Guidelines. These Guidelines have been adopted by the HSE for all new building and refurbishment projects.

Name of ward

Speciality

No of patient beds

No of single rooms


scoreAssessment

scoreComments

There is a family room available 1

Family room is located within the ward itself or as close to the ward as possible 1

Family room is clearly signposted 1

Suitable vacant/engaged signage is used at the door to the room

1

Family room can accommodate 8 people comfortably

3

Family room has sofa bed/sleepover facilities

3

Family room has kitchenette including kettle, fridge, toaster, microwave

3

Room maintains privacy 2

TV is available 1

Room contains high quality furniture (including sofas) in good condition

3

Family room contains suitable art-work which enhances the environment

3

Lighting fixtures are controllable 1

Family room has access to a toilet and shower 1

Family room has access to natural light 2

Family room is accessible to patients & families at all times 1

Family room is painted / decorated which makes it warm and welcoming

3

Total 30





81

Appendix 3 Topic Guides

Topic Guide for Bereaved Relatives/Friends/ NOK Semi Structured Interviews

OPENING

1. (ESTABLISH RAPPORT) Introductions e.g. my name is ….

2. (PURPOSE) I would like to talk to you about the Bereavement Suite

3. (TIMELINE) The interview will take approximately 30 minutes

4. (CONSENT) Complete Informed Consent

Opening Question: Can you tell us about your experience of using the Bereavement Suite?

Questions (in categories) Prompt Questions

Design Features for dignified care

What design features do you like best and why?

or affect you?

during this time? And if not, what features do you

believe are required to meet the needs of future

families or friends? Has the Design & Dignity space

achieved this?

Art features? Paint colours? Lighting?

Too small? Windows/natural light?

Calming effect? Could you pause for

breath there?

e.g. for family room features

- Private?

- Self-contained

e.g. for mortuary

- Was there enough space for all family?

Accessible/Use

that purpose?

Facilities

Toilets/entrances/parking

Signage

Are signs clear? Are directions clear?

Where is it located?

To what extent is it being used? Is it being

used by its intended group?

If not, why?

Atmosphere

Social & emotional aspects

give?

Sanctuary, private, dignified

Art, colours, nature, views

Culture of Care

healthcare care providers, family, friends and other

people using the room?

inclusive of it?

certain religions (e.g. cross)

Could you clarify?

Could you give me an example?

Could you please elaborate?

If so, how?

Can you give us an example?

Closing question: Is there anything we haven’t raised during the interview that you think is important for

us to hear about the build…/ Design & Dignity project?


82

Appendix 3 Topic Guides continued

Topic guide for Healthcare and Support Staff Focus Group

OPENING

1. (ESTABLISH RAPPORT) Introductions e.g. my name is ….

2. (PURPOSE) I would like to talk to you about the Design & Dignity space

3. (TIMELINE) The interview will take approximately 60 mins

4. (CONSENT) Confirm Informed Consent with participants

Opening Question(s): Can you tell us about your involvement in the Design & Dignity Project? What was

your role in the Design & Dignity project? What was your experience of using the Design & Dignity space?

Questions (in categories) Prompt Questions

Culture of care

Open question: How would you describe culture of end-of-life

care here at (Insert hospital name)

- Specific examples (cases) e.g. Bereavement Suite, Family

Room, Mortuary, ED Suite, Maternity Bereavement Suite.

for your patients at end of life and their families or

friends, if at all?

atmosphere for yourselves and other colleagues, if at all?

development of this new space / room, if at all?

anything to you about this space? If so, what?

Inclusive/spirituality

of faiths? If not, has that ever caused a problem in your

experience?

Pride? Confidence or abilities?

Use case probes to elaborate and

clarify

Enhanced your ability to support

families?

Better communication? Family and

patient have opportunities to have

more privacy/intimacy

Does it have relics of certain religions

which can be removed (e.g. cross)

Design Features for dignified care

patients/family needs in their end-of-life care?

space?

incorporated in the Design & Dignity guidelines for (insert

case specific e.g. Bereavement Suite, Family Room,

Mortuary, ED Suite, Maternity Bereavement Suite)

you like least (if any) and why?

how? What have you noticed?

Design features that support privacy?

Kitchenette support nourishment. Sofa

bed for rest. Art work for distraction /

uplift

Views of nature, natural light?

Colours, furnishings, art

E.g. no television. computer, shower,

garden, landline, microwave, toaster,

other art work


83

Appendix 3 Topic Guides continued

Accessible/Use

easy is it to access for patients/family or their

friends?

Intended versus actual use

being used? Is it being used the way it was planned

or intended? In what other ways is the space being

used that’s unrelated to end-of-life care?

Is it user friendly? Examples of facilities:

toilets – are they near? Wheelchair

friendly?

Entrances- wheelchair friendly?

Parking – close to facility? Enough spaces?

Signage

Are signs clear? Where is it located? How is

the experience of way finding for visitors

To what extent is it being used?

Sustainability

is properly looked after/maintained?

are they? (See below)

improve features?

involved in the project?

chance to do it again?

A fund to replace furniture, Standard

Operational Procedures for cleaning,

maintenance etc.

Atmosphere

give?

Sanctuary, private, dignified

colours, art, nature

Overall impact

(1) patient care

(2) family care

(3) you as a staff member,

(4) the overall culture within the ward/department

ward/hospital?

having been involved in this project?

Closing question:

Is there anything we haven’t raised during the interview that you think is important for us to hear about

the build…/ Design & Dignity project?

Has there been any knock on effects of the build or any unforeseen changes? (Gives staff the

opportunity to tell narrative)


84

Appendix 4 Light and Sound Recommendations for Hospital Settings

Sound (Decibels)

Reference:

1Environmental Protection Agency (EPA) (1974)

Information on levels of environmental noise requisite

to protect public health and welfare with an adequate

margin of safety, Government Printing Office,

Washington, DC

2World Health Organisation (2009) Night Noise

Guidelines for Europe. WHO Regional Office for Europe.

Denmark

Maximum noise levels of 45 dB(A)

in hospitals (day)1.

Maximum levels of 30 to 40 dB(A)

in patients’ rooms (night)2.

Light (lux)

Reference:

Garg, N., Kant, S., Gupta, S.K. and Garg, R. (2017).

Study of compliance to prescribed lighting standards in

hospitals of Delhi NCR, India. International Journal of

Research in Medical Sciences, 4(8), pp.3360-3364.

Recommendedlevel of lighting

Hospital Area


85

Theme 1 Meaningful Change

Subtheme Impact on Family Impact of Staff Impact of Care Delivery

Code

from it all (escape/

seclusion)

reflect

ward/Never too far away

environment

embarrassment

family

to visitors

wide interest in private

spaces

to end-of-life care

compassion

those grieving

conversations

confidentiality

environment

Theme 2 Design Features

Subthemes Self-contained Artwork Themed Colour

Use

Sense of

Space

Non-Clinical

Environment

Code

facility themes

palette (lime

green and

purple)

nature

light

home

furnishings

feel

Appendix 5 Qualitative Themes, Subthemes and Codes

Theme 3 Accessibility

Subthemes Needs assessment Security Signage

Code First come, first serve

approach

Prioritise those traveling

Negotiating the shared space

Surveillance versus open

access

Security of locking the door

Local Policy

Well sign posted

Intuitive way finding

Theme 4 Purpose

Subtheme Meetings Dedicated space for refuge Respecting dignity and privacy

Code

meetings

meetings

family and patients

patients to go

news

conversations

conversation


86

Appendix 6 Comment box responses

Quality Improvements undertaken on foot of feedback: a wall mounted TV is being fitted along with the provision of a paper

towel dispenser and cleaning supplies. The kettle which was broken during a week of the data collection period of this study was

replaced immediately and a supply of Delph cups replacing those that were removed were also purchased.

Participants

In total 17 comment cards were collected from the Mater Misercordiae University Hospital,

Dublin. Those who completed a comment card included family members (n=13: 76.4%),

patients (n=3: 17.6%) and staff (n=1: 5.9%).

Negative Aspects of the Family Room

Family members identified the need for additional space (n=2). With regard to usability and

the physical features family members highlighted issues with a broken kettle (n=4); having

no access to a TV (n=2); cutlery (n=1); or microwave (n=1). The room also requires a bigger

fridge (n=1) and additional catering supplies (n=1). One family member reported that no

bedding was available (n=1). Patients also highlighted issues in relation to the kettle not

working (n=1) and room cleanliness (n=1). One staff member suggested incorporating a TV

into the space (n=1).

Areas for Improvement

Family members identified the need for a TV (n=4); additional space (n=1); the removal of

styrofoam cups (n=1); incorporation of a fish tank for relaxation purposes (n=1); and fold

out chairs for overnight stays (n=1). It was also suggested that the room should have higher

seated chairs for impaired visitors (n=1); cushions for sofas (n=1); access to a microwave

(n=1) and a toaster (n=1). Providing a selection of music (n=1) and supplying cleaning

products for visitors (n=1) were also advised. Patients also provided recommendations for

including a TV (n=2) and a microwave (n=1), as well as providing additional complimentary

items (n=1).

Positive Aspects of the Family Room

Family members described the atmosphere as calming and relaxing (n=3); quiet and peaceful

(n=2); non clinical (n=1); spacious (n=1) and welcoming (n=1). They also described it as a

place to be alone (n=1); a place to be with family (n=1); a room to bring visitors together

away from the ward (n=1); and a nice space (n=2). One family member stated that the room

thoughtfully used the design and dignity scheme, showing value for money while remaining

welcoming. In terms of the physical feature the couches were identified as comfortable

(n=1); and suitably long (n=1); and the kitchenette homely (n=2); with the added benefits of

having access to a fridge (n=1). The room had a practical layout with proportionate furniture

(n=1); a classic colour scheme (n=2); beautiful artwork (n=1); and artwork applicable to all

ages (n=1). Patients identified the room as a space to talk with family members (n=1) and

additional room which they could reside in (n=1). One staff member described the room as

relaxing, clean and fresh (n=1).

Comment Card Data

Mater Misercordiae UniversityHospital, Dublin

Family Room

The Evaluation of the Design & Dignity Programme was

commissioned by the Irish Hospice Foundation through the

All Ireland Institute of Hospice and Palliative Care and carried

out by University College Cork. Published 2019.

evaluation of the design & dignity - hospicefoundation.ie · and calm cannot be underestimated....

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